HomeMy WebLinkAboutAgreement A-18-234 with CCFMG.pdfCOUNTY OF FRESNO
Fresno, CA
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PSYCHIATRIC SERVICES AGREEMENT
THIS AGREEMENT is made and entered into this ___________day of _____________, 2018,
by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
hereinafter referred to as “COUNTY”, and, Central California Faculty Medical Group, Inc.
(CCFMG), a California professional corporation, whose address is 2625 East Divisadero Street,
California, 93721, hereinafter referred to as “CONTRACTOR,” collectively, “the parties.”
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), has a need for
licensed psychiatrists in order to provide psychiatric services to clients, as well as additional services
required by COUNTY as stated herein; and
WHEREAS, CONTRACTOR is qualified and willing to provide licensed psychiatrists needed
by the COUNTY pursuant to the terms and conditions of this Agreement.
WHEREAS, CONTRACTOR is an affiliate of UNIVERSITY FACULTY ASSOCIATES, INC.
(UFA), and UFA is the LICENSEE as defined in that certain License Agreement LA-034 with
COUNTY.
WHEREAS, COUNTY and CONTRACTOR mutually desire that CONTRACTOR provide
services pursuant to this Agreement in COUNTY-owned Office Space that is being provided pursuant to
License Agreement LA-034;
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1.SERVICES
A.CONTRACTOR shall perform all services and fulfill all responsibilities as set
forth in Exhibit A, attached hereto and by this reference incorporated herein and made part of this
Agreement.
B.It is acknowledged by all parties hereto that COUNTY's DBH shall monitor the
services provided by CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement.
C.CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
consisting of staff from COUNTY's DBH to discuss service requirements, data reporting, training,
Agreement No. 18-234
1st May
COUNTY OF FRESNO
Fresno, CA
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policies and procedures, overall program operations and any problems or foreseeable problems that may
arise.
2.TERM
This Agreement shall become effective on the 1st day of May, 2018 and shall terminate
on the 30th day of June, 2021.
This Agreement may be extended for two (2) additional twelve (12) month periods upon
the written approval of both parties not later than sixty (60) days prior to the close of the then current
Agreement term. The COUNTY’s DBH Director or designee is authorized to execute such written
approval on behalf of COUNTY based on CONTRCTOR’s satisfactory performance.
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 CONTRACTOR thirty (30) days advance written notice.
B.Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
3)A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
any breach of this Agreement or any default which may then exist on the part of CONTRACTOR.
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment
to the COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the
judgment of COUNTY were not expended in accordance with the terms of this Agreement. The
CONTRACTOR shall promptly refund any such funds upon demand or at COUNTY’s option such
repayment shall be deducted from future payments owing to CONTRACTOR under this Agreement.
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C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY upon the giving of sixty (60) days advance written notice of
an intention to terminate to CONTRACTOR.
D.CONTRACTOR may terminate this Agreement. If terminated by
CONTRACTOR, termination shall require sixty (60) days advance written notice of intent to terminate
(with allowance for appropriate clinical transition of clients prior to termination of services), transmitted
by CONTRACTOR to COUNTY by Certified or Registered U.S. Mail, Return Receipt Requested,
addressed to the office of COUNTY as follows:
Director (or designee)
Department of Behavioral Health
3133 N. Millbrook
Fresno, CA 93703
4.COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with the budget set forth in Exhibit B, attached hereto and by this reference
incorporated herein and made part of this Agreement.
A.Maximum Contract Amount
The maximum amount payable to CONTRACTOR for the ramp up period (May 1, 2018
through June 30, 2018) shall not exceed Three Hundred Thirty-Six Thousand Two Hundred Fifty-Three
and No/100 Dollars ($336,253.00).
The maximum amount payable to CONTRACTOR for the initial operational period (July
1, 2018 through June 30, 2019) shall not exceed Three Million Eight Hundred Eighty-One Thousand
Two Hundred Sixty and No/100 Dollars ($3,881,260.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2019 through
June 30, 2020 shall not exceed Six Million Four Hundred Ninety-Seven Thousand Two Hundred
Eighty-Eight and No/100 Dollars ($6,497,288.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2020 through
June 30, 2021 shall not exceed Nine Million Four Hundred Eighty-Five Thousand Seven Hundred Sixty-
Three and No/100 Dollars ($9,485,763.00).
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The maximum amount payable to CONTRACTOR for the period of July 1, 2021 through
June 30, 2022 shall not exceed Thirteen Million One Hundred Fifty-Three Thousand Eight Hundred
Thirty and No/100 Dollars ($13,153,830.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2022 through
June 30, 2023 shall not exceed Fourteen Million Four Hundred Ninety-Five Thousand One Hundred
Eighty-Two and No/100 Dollars ($14,495,182.00).
In no event shall the maximum contract amount for all the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess of Forty-
Seven Million Eight Hundred Forty-Nine Thousand Five Hundred Seventy-Six and No/100 Dollars
($47,849,576.00) during the total term of this Agreement.
Payment shall be made upon certification or other proof satisfactory to COUNTY’s DBH
that services have actually been performed by CONTRACTOR as specified in this Agreement.
B. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply
with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
C. Payments shall be made by COUNTY to CONTRACTOR in arrears, for 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 actual expenditures incurred by CONTRACTOR for monthly program
costs, as identified in Exhibit B, in the performance of this Agreement and shall be documented to
COUNTY on a monthly basis by the tenth (10th) of the month following the month of said expenditures.
The parties acknowledge that the CONTRACTOR will be performing hiring, training, and credentialing
of staff, and the COUNTY will be performing additional staff credentialing to ensure compliance with
State and Federal regulations.
D. 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.
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All final invoices shall be submitted by CONTRACTOR 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 pursuant to the terms and conditions of this Agreement shall
automatically revert to COUNTY.
E.The services provided by CONTRACTOR 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. 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.
F.CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR’s deficiency discovered through the State audit
process and COUNTY utilization review during the course of this Agreement. At COUNTY’s election,
the disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or
shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive
reimbursement for any units of services rendered that are disallowed or denied by the Fresno County
Mental Health Plan (Mental Health Plan) utilization review process or through the State Department of
Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients.
Notwithstanding the above, COUNTY must notify CONTRACTOR prior to any State audit process
and/or COUNTY utilization review. To the extent allowable by law, CONTRACTOR shall have the
right to be present during each phase of any State audit process and/or COUNTY utilization review and
shall be provided all documentation related to each phase of any State audit process and/or COUNTY
utilization review. Additionally, prior to any disallowances/audit exceptions becoming final,
CONTRACTOR shall be given at least 10 business days to respond to such proposed
disallowances/audit exceptions.
G.It is understood by CONTRACTOR and COUNTY that this Agreement is funded
with mental health funds to serve adult individuals with Severely Mentally Ill (SMI) disorders and
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children/youth with Seriously Emotionally Disturbed (SED) disorders, many of whom have co-
occurring substance use disorders. It is further understood by CONTRACTOR and COUNTY that
funds shall be used to support appropriately integrated and documented treatment services for co-
occurring mental health and substance use disorders.
H.COUNTY and CONTRACTOR recognize the importance of maintaining a highly
productive workforce to help achieve reductions in client wait times, cancellations and appointment no-
shows. Therefore, CONTRACTOR will initiate a compensation incentive plan (CIP) for
CONTRACTOR’s employees providing direct client care under this Agreement which will directly link
direct client care productivity to compensation increases for CONTRACTOR’s staff. “Direct client
care” is defined as the time CONTRACTOR’s staff spends seeing a client plus the time
CONTRACTOR’s staff spends documenting the client visit in a manner ensuring completeness and
compliance with all regulations required for the COUNTY to submit claims to State DHCS for Federal
and State reimbursement for direct client care delivered by CONTRACTOR’s staff to Medi-Cal eligible
clients.
The CIP model will be based upon units of productivity where one (1) unit
equates to a client follow up visit, and three (3) units equates to a new client intake visit. The CIP
contemplates both an eight (8) hour workday and a ten (10) hour workday and begins to incentivize
psychiatrists at 60% productivity as shown below. The maximum incentive of 20% is achieved at 75%
productivity for direct client care.
Average Units
(8 hr.)
Average Units
(10 hr.)
Direct
Client Care
Total %
Compensation
9.6 12.0 60% 3.0%
10.1 12.6 63% 6.0%
10.6 13.2 66% 9.0%
11.0 13.8 69% 12.0%
11.5 14.4 72% 15.0%
12.0 15.0 75% 20.0%
The units of productivity will be reconciled by the CONTRACTOR at the end of
each fiscal quarter (ending September, December, March, June) and CONTRACTOR shall pay the
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additional compensation set forth in the above table to CONTRACTOR’s staff based upon the
productivity achieved by each psychiatrist pursuant to the CIP. CONTRACTOR shall invoice
COUNTY for additional compensation paid to CONTRACTOR’s staff pursuant to Paragraph 5 of this
Agreement.
I.COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation for annual administrative costs not to exceed a maximum of fifteen percent (15%) of the
total annual budget.
5.INVOICING
A.CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) business
day of each month for the prior month’s actual services rendered to DBHInvoices@co.fresno.ca.us.
After CONTRACTOR renders services, and certifies the hours worked by CONTRACTOR’s staff,
CONTRACTOR shall invoice COUNTY for payment. COUNTY must pay CONTRACTOR before
submitting claims to State DHCS for Federal and State reimbursement for Medi-Cal eligible clients.
B.At the discretion of COUNTY’s DBH Director, or designee, if an invoice is
incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director, or 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. CONTRACTOR 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 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 designee, COUNTY’s DBH shall have the right to deny
payment of any additional invoices received.
C.CONTRACTOR must maintain financial records for a period of ten (10) years or
until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be
responsible for any disallowances related to inadequate documentation.
D. CONTRACTOR is responsible for collection and managing of data in a manner to
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be determined by DHCS and the COUNTY’s Mental Health Plan in accordance with applicable rules
and regulations. COUNTY’s electronic information system is a critical source of information for
purposes of monitoring service volume and obtaining reimbursement.
E.CONTRACTOR shall submit service data into COUNTY’s electronic information
system according to COUNTY’s DBH documentation standards to allow the COUNTY to bill Medi-
Cal, and any other third-party source, for services and meet State and Federal reporting requirements.
F.CONTRACTOR must comply with all laws and regulations governing the
Federal 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 regulations and rules promulgated by the Federal Centers for
Medicare and Medicaid Services as they relate to participation, coverage and claiming reimbursement.
CONTRACTOR will be responsible for compliance as of the effective date of each Federal, State or
local law or regulation specified.
G.Data entry shall be the responsibility of the CONTRACTOR. COUNTY shall
monitor the volume of services and cost of services entered into the COUNTY’s electronic information
system. Any and all audit exceptions resulting from the provision and reporting of specialty mental
health services by CONTRACTOR shall be the sole responsibility of the CONTRACTOR.
CONTRACTOR will comply with all applicable policies, procedures, directives and guidelines
regarding the use of COUNTY’s electronic information system.
H.Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR shall comply with any and all requests and directives associated
with COUNTY maintaining State Medi-Cal site certification. CONTRACTOR shall provide specialty
mental health services in accordance with the COUNTY’s Mental Health Plan. CONTRACTOR must
comply with the “Fresno County Mental Health Plan Compliance Program and Code of Conduct” set
forth in Exhibit C, attached hereto and incorporated herein by reference and made part of this
Agreement. CONTRACTOR shall comply with any and all requests associated with any State/Federal
reviews or audits.
CONTRACTOR may provide direct specialty mental health services using pre-
licensed staff as long as the individual is approved as a provider by the Mental Health Plan, is
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supervised by licensed staff, works within his/her scope and only delivers allowable direct specialty
mental health services. 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 set
off from other payments due the amount of said disapproved services. CONTRACTOR 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 under
this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’s officers, agents, and employees will at all times be acting and performing as an
independent CONTRACTOR, and shall act in an independent capacity and not as an officer, agent,
servant, employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have
no right to control or supervise or direct the manner or method by which CONTRACTOR shall perform
its work and function. However, COUNTY shall retain the right to administer this Agreement so as to
verify that CONTRACTOR is performing their obligations in accordance with the terms and conditions
thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the
rules and regulations, if any, of governmental authorities having jurisdiction over matters, which are
directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
solely liable and responsible for providing to, or on behalf of, its employees all legally-required
employee benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY
harmless from all matters relating to payment of CONTRACTOR’s employees, including compliance
with Social Security, withholding, and all other regulations governing such matters. It is acknowledged
that during the term of this Agreement, CONTRACTOR may be providing services to others unrelated
to COUNTY or to this Agreement.
CONTRACTOR will execute written contracts of employment with psychiatrists who
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will perform services on behalf of CONTRACTOR pursuant to this Agreement. Any such agreements,
whether employment contracts, professional services contracts, or independent contractor agreements,
shall include the following language, in a separate paragraph, separately initialed by the physician:
“[NAME OF PHYSICIAN] acknowledges that he or she will be providing professional
services at facilities owned and/or operated by the County of Fresno, and, at times, in
conjunction with employees of the County of Fresno. It is mutually understood and
agreed that in the performance of such duties, [PHYSICIAN] will at all times be acting
and performing as an employee [or independent contractor] of CCFMG and not as an
employee of the County of Fresno. [PHYSICIAN] acknowledges that he or she shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CCFMG is solely liable and responsible for providing [PHYSICIAN] with all legally-
required employee benefits.
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, staffing, and responsibilities of the
CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health treatment, as
set forth in Exhibit A, may be made with the signed written approval of COUNTY’s DBH Director or
designee and CONTRACTOR through an amendment approved by COUNTY’s County Counsel and the
COUNTY’s Auditor-Controller’s Office.
In addition, changes to expense category (i.e., Salary & Benefits, Facilities/Equipment,
Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, as set forth
in Exhibit B, that do not exceed 10% of the maximum compensation payable to the CONTRACTOR
may be made with the written approval of COUNTY’s DBH Director, or designee.
Said modifications shall not result in any change to the annual maximum compensation
amount payable to CONTRACTOR, as stated in this Agreement.
8.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
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under this Agreement without the prior written consent of COUNTY.
9. HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY
in connection with the negligent performance, or failure to perform, by CONTRACTOR, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including attorney
fees and court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the negligent performance, or failure to perform, of
CONTRACTOR, their officers, agents or employees under this Agreement. CONTRACTOR further
agrees to indemnify, save, hold harmless, and at COUNTY's request, defend COUNTY, its officers,
agents and employees from any and all costs and expenses, including attorney fees and court costs,
damages, liabilities, claims and losses occurring or resulting to COUNTY in the event that any person(s)
employed or retained by CONTRACTOR to provide services pursuant this Agreement make claims that
he/she/they are employees of the COUNTY by virtue of being employed or retained by
CONTRACTOR.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10. INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or
any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and affect 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 Five Million
Dollars ($5,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire
legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
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B.Automobile Liability
Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or
if Consultant has no owned autos, Code 8 (hired) and 9 (non-owned).with limits
for bodily injury of not less than Five Hundred Thousand Dollars ($500,000) per
person and with limits no less than One Million Dollars ($1,000,000) per accident
for bodily injury and property damage. Coverage should include owned, non-
owned, and hired vehicles used in connection with this Agreement.
C.Real and Property Insurance
CONTRACTOR 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 (21) of this Agreement.
All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of
the COUNTY’S personal property in possession of CONTRACTOR 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.
D.Professional Liability
Professional Liability Insurance with limits of not less than One Million Dollars
($1,000,000) per occurrence, Three Million Dollars ($3,000,000) annual
aggregate. CONTRACTOR agrees that it shall maintain, at its sole expense, in
full force and effect for a period of three (3) years following the termination of
this Agreement, one or more policies of professional liability insurance with
limits of coverage as specified herein.
E.Child Abuse/Molestation and Social Services Coverage
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.
F.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
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California Labor Code.
CONTRACTOR 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 CONTRACTOR signs this Agreement,
CONTRACTOR 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, 3133
N. Millbrook Ave, Fresno, California, 93703, Attention: Contracts Division, 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 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 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.LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR 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 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 and CONTRACTOR’s staff shall comply with all
applicable laws, rules or regulations, as may now exist or be hereafter changed.
12.RECORDS
CONTRACTOR shall maintain records in accordance with Exhibit D, "Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part
of this Agreement. COUNTY shall be allowed to review all records of services provided, including the
goals and objectives of the treatment plan, and how the therapy provided is achieving the goals and
objectives.
13.REPORTS
A.Outcome Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
reasonably requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to
change at COUNTY’s DBH discretion.
B.Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
data, and other information as COUNTY’s DBH may reasonably request pertaining to matters covered
by this Agreement. In the event that CONTRACTOR 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 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.
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C.Cost Report
CONTRACTOR shall provide financial data to identify all direct and indirect
costs incurred by the CONTRACTOR for all services delivered under this Agreement. All Cost Reports
must be prepared in accordance with Generally Accepted Accounting Principles (GAAP) and Welfare
and Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3) and 5718(c). Unallowable costs such as
lobbying or political donations must be deducted on the cost report and monthly invoice
reimbursements.
D.Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and
CONTRACTOR agree to settle dollar amounts disallowed or settled in accordance with DHCS audit
settlement findings related to the reimbursement provided under this Agreement. CONTRACTOR will
participate in the several phases of settlements between COUNTY/CONTRACTOR and DHCS. The
phases of initial cost reporting for settlement according to State reconciliation of records for paid Medi-
Cal services and audit settlement are: State DHCS audit 1) initial cost reporting - after an internal review
by COUNTY, the COUNTY files the 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 18 to 36 months following the State close of the fiscal year, DHCS will send notice for
any settlement under this provision to the COUNTY; 3) Audit Settlement-State DHCS audit. After final
reconciliation and settlement DHCS may conduct a review of medical records, cost report along with
support documents submitted to COUNTY in initial submission to determine accuracy and may disallow
costs and/or units of services. COUNTY may choose to appeal and therefore reserves the right to defer
payback settlement with CONTRACTOR 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, it will require the CONTRACTOR to repay
the Medi-Cal related overpayment back to the COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification
by the COUNTY, or COUNTY shall withhold future payments until all excess funds have been
recouped by means of an offset against any payments then or thereafter owing to COUNTY under this
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or any other Agreement between the COUNTY and CONTRACTOR.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
the State Department of Health Care Services, or their designees, the right to review and monitor
records, services or procedures, at any time, in regard to clients, as well as the overall operation of
CONTRACTOR’s performance, in order to ensure compliance with the terms and conditions of this
Agreement.
15.REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment.
16.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department Health Care Services, and that under said agreement
the State imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall
adhere to all State requirements, including those identified in Exhibit E “State Mental Health
Requirements”, 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 Protocol and using the Worksheet identified in Exhibit F, attached hereto and by this
reference incorporated herein and made part of this Agreement or a protocol and worksheet presented
by CONTRACTOR that is accepted by COUNTY’s DBH Director or designee.
17.COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall inform every client of their rights under the COUNTY's Mental
Health Plan as described in Exhibit G, attached hereto and by this reference incorporated herein and
made part of this Agreement.
18.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
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confidentiality.
19. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
104-191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security
of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated
thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations) and other
applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504€ of the Code of
Federal Regulations.
20. 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 by the COUNTY, including but not limited to the following:
A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1) CONTRACTOR has received authorization by COUNTY for telecommuting
purposes;
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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-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief
Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C.COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on
non-COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer,
and/or designee(s).
D.CONTRACTOR 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 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 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.
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H.COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information provided
to CONTRACTOR. CONTRACTOR 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 will be
responsible for all costs incurred as a result of providing the required notification.
21.PROPERTY OF COUNTY
A.COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items
will be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1. Asset must have life span of over one year.
2.The asset is not a repair part
3. The asset must be valued at or greater than the capitalization thresholds for the
asset type
Asset type Threshold
•land $0
•buildings and improvements $100,000
•infrastructure $100,000
•be tangible $5,000
o equipment
o vehicles
•or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
•and capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed asset
log will be maintained by COUNTY’s Asset Management System and annual inventoried until the asset
is fully depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be
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inventoried in comparison to COUNTY’s DBH Asset Inventory System.
B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are sensitive
assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and other
sensitive items as determined by COUNTY’s DBH Director or designee. CONTRACTOR maintains a
tracking system on the items and are not required to be capitalize or depreciated. The items are subject
to annual inventory for compliance.
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in
an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of
this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
unable to produce the assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1. To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2. To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used, in accordance with procedures developed by COUNTY.
All such lists shall be submitted to COUNTY within ten (10) days of any request therefore; and
3. To report in writing to COUNTY immediately after discovery, the lost or
theft of any items of equipment. For stolen items, the local law enforcement agency must be contacted
and a copy of the police report submitted to COUNTY.
D. The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of this
Agreement as appropriate, and must be directly related to CONTRACTOR’s services or activity under
the terms of this Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from
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equipment purchased, which are incurred by CONTRACTOR, if prior written approval has not been
obtained from COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY’s DBH
whenever there is any modification or change in the use of any property acquired or improved, in whole
or in part, using funds under this Agreement. If any real or personal property acquired or improved with
said funds identified herein is sold and/or is utilized by CONTRACTOR for a use which does not
qualify under this Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal to the
current fair market value of the property, less any portion thereof attributable to expenditures of funds
not provided under this Agreement. These requirements shall continue in effect for the life of the
property. In the event this Agreement expires, or terminates, the requirements for this Section shall
remain in effect for activities or property funded with said funds, unless action is taken by the State
government to relieve COUNTY of these obligations
22.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services, because of
race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age
or gender, pursuant to all applicable State and Federal statutes and regulations.
23.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of
four (4) years after the furnishing of services under this Agreement, CONTRACTOR shall make
available, upon written request to the Secretary of the United States Department of Health and Human
Services, or upon request to the Comptroller General of the United States General Accounting Office, or
any of their duly authorized representatives, a copy of this Agreement and such books, documents, and
records as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event
CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value
or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period,
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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.
24.SINGLE AUDIT CLAUSE
A. If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars ($750,000.00)
or more in Federal and Federal flow-through monies, CONTRACTOR 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) Circular A-133. CONTRACTOR shall submit said audit and management letter to
COUNTY. The audit must include a statement of findings or a statement that there were no findings. If
there were negative findings, CONTRACTOR must include a corrective action plan signed by an
authorized individual. CONTRACTOR 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. All audit costs related to this Agreement are the
sole responsibility of CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR’s Federal contracts do
not exceed the Seven Hundred Fifty Thousand 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
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
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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 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 paragraph shall be billed to the CONTRACTOR at COUNTY cost, as determined by COUNTY’s
Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the
Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
period of at least three (3) years following final payment under this Agreement or the closure of all other
pending matters, whichever is later.
25. COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached hereto and
incorporated herein by reference and made part of this Agreement. Within thirty (30) days of entering
into this Agreement with the COUNTY, CONTRACTOR 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 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 understands that the promotion of and adherence to the Code of Conduct is an element
in evaluating the performance of CONTRACTOR 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
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subcontractors shall attend the appropriate training within 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, Fresno, California 93703.
CONTRACTOR 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.
26.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither it, nor any of its
officers, are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs; that neither it, nor any of its officers, have been convicted of a criminal offense
related to the provision of health care items or services; nor has it, or any of its officers, been reinstated
to participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or
ineligibility. If COUNTY learns, subsequent to entering into a contract, that CONTRACTOR is
ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility for, or
involvement with, COUNTY’s business operations related to the Federal Health Care Programs and
shall remove such CONTRACTOR from any position in which CONTRACTOR’s compensation, or the
items or services rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part,
directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until
such time as CONTRACTOR is reinstated into participation in the Federal Health Care Programs.
A.If COUNTY has notice that either CONTRACTOR, or its officers, 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 and COUNTY shall take all appropriate
actions to ensure the accuracy of any claims submitted to any Federal Health Care Program. At its
discretion given such circumstances, COUNTY may request that CONTRACTOR cease providing
services until resolution of the charges or the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
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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 participate in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility.
1. In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
hires or engages such potential employee or subcontractor, CONTRACTOR will ensure that said
employee or subcontractor does no work, either directly or indirectly relating to services provided to
COUNTY.
2.Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 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 will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined
by COUNTY to protect the interests of COUNTY consumers.
C.CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected to
perform professional services under this Agreement (1) are not currently excluded, suspended, debarred,
or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted
of a criminal offense related to the provision of health care items or services; and (3) have not been
reinstated to participate in the Federal Health Care Program after a period of exclusion, suspension,
debarment, or ineligibility. In the event any existing employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to participate in
the Federal Health Care Programs, or has been convicted of a criminal offense relating to the provision
of health care services, CONTRACTOR will ensure that said employee or subcontractor does no work,
either direct or indirect, relating to services provided to COUNTY.
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1. CONTRACTOR agrees to notify COUNTY immediately during the term
of this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each
case, is providing professional services under 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 3 of this Agreement, or require adequate assurance (as defined by
COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined
by COUNTY to protect the interests of COUNTY consumers.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating
to CONTRACTOR’s compliance with the provisions of this Section.
E. CONTRACTOR 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.
27. 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 designee and at a cost to be provided in
Exhibit B for such items as written/printed materials, the use of media (i.e., radio, television,
newspapers) and any other related expense(s).
28. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client
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or a client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries
concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (l 0th) day of the
following month, in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide
details and attach documentation of each complaint with the log. CONTRACTOR shall post signs
informing clients of their right to file a complaint or grievance. CONTRACTOR 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 clients,
CONTRACTOR 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 shall inform every client of their rights as set
forth in Exhibit G. CONTRACTOR shall file an incident report for all incidents involving clients,
following the protocol and using the worksheet identified in Exhibit F and incorporated herein by
reference and made part of this Agreement.
29.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104,
and 455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR by completing Exhibit H, “Disclosure
of Ownership and Control Interest Statement”, attached hereto and by this reference incorporated herein
and made part of this Agreement. CONTRACTOR shall submit this form to the COUNTY’s DBH
within thirty (30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall
report any changes to this information within thirty-five (35) days of occurrence by completing Exhibit
H, “Disclosure of Ownership and Control Interest Statement.” Submissions shall be scanned pdf copies
and are to be sent via email to DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
30.DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
COUNTY OF FRESNO
Fresno, CA
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CONTRACTOR 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”):
A.Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
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-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 from further business consideration. The information will be considered as part of
the determination of whether to continue and/or renew this Agreement and any additional information
or explanation that a CONTRACTOR elects to submit with the disclosed information will be
considered. If it is later determined that the CONTRACTOR failed to disclose required information,
any contract awarded to such CONTRACTOR may be immediately voided and terminated for
material failure to comply with the terms and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension,
and Other Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit I,
attached hereto and by this reference incorporated herein and made part of this Agreement.
Additionally, CONTRACTOR must immediately advise the COUNTY’s DBH in writing if, during the
term of this Agreement: (1) CONTRACTOR becomes suspended, debarred, excluded or ineligible for
participation in federal or state funded programs or from receiving federal funds as listed in the excluded
parties’ list system (http://www.epls.gov); or (2) any of the above listed conditions become applicable to
COUNTY OF FRESNO
Fresno, CA
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CONTRACTOR. CONTRACTOR shall indemnify, defend and hold the COUNTY harmless for any
loss or damage resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in
the signed Certification Regarding Debarment, Suspension, and Other Responsibility Matters.
31.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
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 is providing goods or performing services
under this Agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR
is a party and in which one or more of its directors has a material financial interest. Members of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing and
signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit J 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.
32.AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours, and as often as the
COUNTY may deem necessary, make available to the COUNTY for examination all of its records and
data with respect to the matters covered by this Agreement. The CONTRACTOR 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 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).
33.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
COUNTY OF FRESNO
Fresno, CA
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Director, Fresno County President and CEO
Department of Behavioral Health Central California Faculty
3133 N. Millbrook Ave Medical Group, Inc. (CCFMG)
Fresno, CA 93702 2625 East Divisadero Street
Fresno, CA 93721
All notices between the COUNTY and CONTRACTOR provided for or permitted under
this Agreement must be in writing and delivered either by personal service, by first-class United States
mail, by an overnight commercial courier service, or by telephonic facsimile transmission. A notice
delivered by personal service is effective upon service to the recipient. A notice delivered by first-class
United States mail is effective three COUNTY business days after deposit in the United States mail,
postage prepaid, addressed to the recipient. A notice delivered by an overnight commercial courier service
is effective one COUNTY business day after deposit with the overnight commercial courier service,
delivery fees prepaid, with delivery instructions given for next day delivery, addressed to the recipient. A
notice delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if
such transmission is completed outside of COUNTY business hours, then such delivery shall be deemed to
be effective at the next beginning of a COUNTY business day), provided that the sender maintains a
machine record of the completed transmission. For all claims arising out of or related to this Agreement,
nothing in this section establishes, waives, or modifies any claims presentation requirements or procedures
provided by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the
Government Code, beginning with section 810).
34.GOVERNING LAW
Venue for any action arising out of or related to the Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
35.ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
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CONTRACTOR
CENTRAL CALIFORNIA FACULTY
MEDICAL GROUP, INC. (CCFMG)
By:fJtL~
Print Name: :;;;q U.1 he-/J.s -l<eer1.e__.
COUNTY OF FRESNO
Title: C:h :e -F L& e <~ 1,() ~ ~
President or Chief Executive Officer
Or any Vice President
ATTEST:
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.£.. · Bernice E. Seidel,
By: C:::..~ Clerk of the Board of Supervisors
County of Fresno, State of California
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Print Name: &en.e.. koJ,lse.f), HD >-D. • A
,,-. t , / n ' ..L By:o~t'" , ~
Title: lA1 Cl l V)Yl 0!] _t....,,e. S.-( J ijL{
t -, '"..., Secretary of Corporation, or Date: b \ l 2.0 ,~
Any Assistant Secretary, or
Chief Financial Officer, or
Any Assistant Treasurer
Mailing Address:
2625 East Divisadero Street
Fresno, CA 93721
Phone No. (559) 453-5200
Contact: Chief Executive Officer
2 7 Fund/Subclass: 0001/10000
Organization: 5630
2 8 Account/Program: 7295/0
-31 -COUNTY OF FRESNO
Fresno, CA
Exhibit A
Page 1 of 11
GENERAL PROVISIONS
The General Provisions listed below will apply to all services to be delivered by
CONTRACTOR under this Agreement.
I.SERVICE STANDARDS:
A.The following provisions set forth in this exhibit shall constitute a part of the
Agreement between the COUNTY and CONTRACTOR, for providing psychiatric
services to COUNTY's Department of Behavioral Health (DBH), Adult Services
Programs, and Children's Services Program, and other programs as approved by
COUNTY’s DBH Director, or designee.
II.SERVICE PERFORMANCE MONITOR :
Name and Title: Susan Holt, LMFT, Deputy Director
Organization: Fresno County Department of Behavioral Health
Street Address: 3133 N. Millbrook Ave.
City and Zip Code: Fresno, CA 93703
III.PROGRAM AND SERVICE REOUIREMENTS :
A.CONTRACTOR shall provide the following throughout the term of this
Agreement:
1.CONTRACTOR shall assign physicians who are qualified and licensed as
psychiatrists pursuant to the laws of the State of California, to COUNTY in
accordance to Section 1 of this Exhibit A of this Agreement.
2.In accordance with Division 5 Part 1 Chapter 4 Section 5405 of the Welfare and
Institutions Code, CONTRACTOR shall submit to criminal history reference
checks, including but not limited to, "Live Scan". CONTRACTOR is solely
responsible for ensuring the completion of this process, including all associated
costs. COUNTY will require additional credentialing by COUNTY for all
CONTRACTOR’s staff. No direct client contact by CONTRACTOR shall occur
prior to written clearance from COUNTY has been given.
3.In the event that recruitment of Physicians is delayed, COUNTY agrees to
maintain utilization of telemedicine services until maximum recruitment is
achieved. Status of recruitment will be reviewed with COUNTY DBH Director,
or designee, quarterly.
B.Director of DBH or designee, and Medical Director shall meet quarterly to discuss
operational and contractual progress. Meetings will cover topics such as, but not
limited to;
1.Recruitment efforts
Exhibit A
Page 2 of 11
2.Clinical operations and multi-disciplinary collaboration and integration
3.Physical plant, security services, technology (EHR, computers, VPN, etc.)
4.Providing and maintaining adequate support for the providers including a Nurse
Manager, OAs, social workers, nurses and therapists, and translation services as
needed.
C.CONTRACTOR’s employees will work within COUNTY facilities subject to the
Facility Use Agreement executed by the Parties in conjunction with this
Agreement. COUNTY will provide office space, computers, office equipment,
basic office supplies, and office furniture necessary to deliver services under this
Agreement. CONTRACTOR will schedule CONTRACTOR’s employees’ work
hours. COUNTY support staff will schedule clients in collaboration with
CONTRACTOR’s medical staff.
D.CONTRACTOR hereby certifies that any staff so assigned to provide services
pursuant to this Agreement shall:
1.Be Post Graduate Year 111 - V (PGY).
2.Have and maintain their license in good standing.
3.Perform professional duties to the best of his or her ability, in accordance
with the highest scientific, professional and ethical standards of the
profession, and in accordance with currently approved methods and practices
in the field of psychiatry.
4.Comply with all applicable Federal State, COUNTY or other governmental
agency laws, ordinances, rules and regulations including CONTRACTOR
policy.
5.Comply with the requirements of all appropriate accrediting bodies, including
COUNTY current and future credentialing and/or accreditation requirements, and
any other State-related requirements.
6.Perform psychiatric related services set forth in Exhibits A-1 and A-2 subject to
such assignments and work hours to be arranged in writing to the mutual
satisfaction of COUNTY and CONTRACTOR. It is understood that COUNTY's
contract monitoring shall not include control or direction regarding diagnosis and
prescription of psychiatric treatment assuming that such diagnosis and treatment
are in accordance with MHP standards and all other requirements pursuant to this
Agreement.
E.Administrative Requirements
1.CONTRACTOR shall provide a Medical Director that shall oversee all aspects of
psychiatric services under this Agreement.
Exhibit A
Page 3 of 11
2.Medical Director shall work collaboratively with other DBH leaders in
clinical and administrative operations.
3.Medical Director shall attend, and actively participate in, specifically identified
COUNTY DBH meetings, including but not limited to
i.Leadership Team Meetings
ii.Clinical Operations Meetings
iii.Compliance Committee
iv.Quality Improvement Committee
v.Intensive Analysis Committee
Additional meetings will be identified during the duration of this
Agreement. Medical Director shall attend not less than 50% of all
requested meetings.
4.Medical Director shall provide consultation services to the DBH Director, DBH
Leadership Team Members, and other designees, as requested by COUNTY.
5.CONTRACTOR’s Medical Director shall participate in the development of
policy and procedures for services pertaining to this Agreement.
6.The Medical Director shall recruit, hire and retain qualified psychiatrists for
COUNTY.
7.Should CONTRACTOR determine that the support of an Administrative
Assistant is required for the Medical Director, CONTRACTOR shall
employee the Administrative Assistant.
F.Staffing
1.COUNTY and CONTRACTOR shall mutually agree on psychiatric
services staffing needs. CONTRACTOR shall have final say on staff
placement.
2.CONTRACTOR shall be responsible for scheduled work hours of
CONTRACTOR’s employees to meet the mutually agreed upon volume
of services needed under this Agreement.
3.In the event a designated staff member does not perform services as required by
this Agreement because of prolonged absence or resignation, or failure to meet
performance standards, CONTRACTOR will provide a replacement.
If CONTRACTOR is unable to provide a replacement within 30 days,
COUNTY may proceed to use other internal or contracted resources. By
mutual agreement of CONTRACTOR and COUNTY, use of COUNTY internal
Exhibit A
Page 4 of 11
or contracted resources shall be utilized prior to 30 days if critical client care needs
are identified.
G. COUNTY and CONTRACTOR will have collaborative clinical oversite of all vendors
providing psychiatric services and staffing, such as; Psychiatrists and/or Nurse
Practitioners. COUNTY retains full authority on all contractual matters of all
COUNTY vendors.
H. CONTRACTOR shall participate in tracking and monitoring of outcome measures,
metrics, and goals on an annual basis with COUNTY.
Such metrics will include, but not be limited to:
1. Timely access to client care.
2. Timely follow-up to crisis.
3. Monitoring appropriateness of polypharmacy.
4. Client satisfaction.
5. Provider satisfaction.
6. No-show rate.
7. Peer review, including adherence to standards of care.
I. CONTRACTOR’s psychiatry staff shall maintain a minimum standard of 32
weekly clinical hours of productivity (per Full Time Equivalent). At least 75%
of productive time shall be direct client care. Overall, productive time will
include:
1. Direct client care.
2. Multidisciplinary clinical collaboration (team meetings, individual case
consultation, etc.).
3. Case review.
4. Providing training for COUNTY’s staff, and network of contracted providers,
as requested by COUNTY DBH
5. Administrative activities (e.g. quality assurance, peer review, pharmacy and
therapeutics committee).
J. Psychiatry staff who are full-time (40 hrs per week) with academic responsibilities
through CONTRACTOR’s affiliation with a medical education program (e.g. UCSF
Fresno) shall be allowed 8 hours of academic time, per week, per FTE. Staff who
are not full-time shall have academic time prorated based on their FTE. Psychiatry
staff without academic responsibilities shall not receive academic time.
Note: FTE represents 32 clinical hours and 8 academic time hours per week.
IV. CONFIDENTIALITY OF INFORMATION :
A. With respect to any information that would identify individual patients receiving
Exhibit A
Page 5 of 11
psychiatric services pursuant to this Agreement that is obtained by CONTRACTOR,
CONTRACTOR shall not use any such information for any purpose other than
carrying out the express terms of this Agreement, provided, however, that nothing
herein shall be constituted to prevent CONTRACTOR from using the information in
publication of research where such publication does not violate patient
confidentiality.
1. CONTRACTOR shall obtain written consent from COUNTY prior to
conducting any research.
2. CONTRACTOR shall at all times be in compliance with COUNTY’s policies
related to research including Institutional Review Board process.
B. Neither party shall release any confidential patient records except as required or
authorized by law or regulation. Each party shall respond to all requests for patient
records in accord with federal and state laws.
V. COUNTY SUPPORT FOR DESIGNATED PHYSICIANS :
A. COUNTY will provide, dependent on program configuration, the following for
CONTRACTOR staff performing services under this Agreement at COUNTY
facilities:
1. Offices for professional use in connection to staff' assignment to perform at
the County facility.
2. Support services appropriate for the COUNTY’s operation of the clinic, which
shall include scheduling of client appointments, reception services, and support for
written correspondence regarding client care.
3. Such nursing and technical personnel, supplies, services and equipment necessary
for the provision of professional psychiatric services.
B. COUNTY shall also:
1. Reserve the right to require typed reports as necessary depending on the data
system used to maintain client activity records.
2. Reserve the right to change, add or delete the meeting obligations of
CONTRACTOR's staff assuming appropriate negotiation with COUNTY’s DBH
Director, or designee.
3. Notify the CONTRACTOR in writing 30 days prior to changing the Service
Performance Monitor.
4. Meet with CONTRACTOR to discuss any changes in proposed service revision.
5. Complete the Reauthorization process for each client annually to provide updates
regarding the client functioning and service plans/goals and continued
Exhibit A
Page 6 of 11
authorization for services.
ADULT MENTAL HEALTH PSYCHIATRIC SERVICES
(County-Operated Clinics)
I. SERVICE LOCATIONS:
Facility Name: Metro Outpatient Clinic Facility Name: Sierra Building
Street Address: 4441 E. Kings Canyon Rd Street Address: 1925 E. Dakota Ave
City and Zip code: Fresno, CA 93702 City and Zip code: Fresno, CA 93726
Facility Name: Senior Resource Center Facility Name: West Fresno Regional Center
Street Address: 2025 E. Dakota Ave Street Address: 188 E. California Ave
City and Zip code: Fresno, CA 93726 City and Zip code: Fresno, CA 93706
The above service locations are COUNTY’s current service locations, and the COUNTY, over the
duration of this Agreement, may add or change service locations.
II. SERVICE REOUIREMENTS :
A. CONTRACTOR shall provide integrated medication support services of co-
occurring mental health and substance use disorders in accordance with MHP
specialty mental health services requirements and documentation standards.
B. COUNTY will provide appropriate billing and documentation training.
C. CONTACTOR shall provide medication support services and support in
accordance with COUNTY policies, and include the following treatment strategies:
1. Medication Evaluation and Monitoring: CONTRACTOR shall offer medication
evaluation and monitoring to each client when clinically indicated. Medication
services will be provided individually or in a group setting. CONTRACTOR
shall provide not less than fifteen minutes of medication services for all clients
within the clinically appropriate timeframe, but not less than three times per year
if stable. Clients who are stable and maintain higher level of recovery shall be
transitioned when appropriate to outside providers.
2. Psychiatrists and/or other members of the medical team will complete the Initial
Psychiatric Assessment at the start of psychiatric service, and the Medication
Service Plan (Avatar CWS) at the start of service, and annually thereafter. All
signature/co-signature requirements must be completed in accordance with
COUNTY DBH policy.
INITIAL PSYCHIATRY BUNDLE
Initial Psychiatric Assessment
Exhibit A
Page 7 of 11
Psychiatric MSE
AIMS
Diagnosis
Order Connect
Medication Service Plan
If applicable any new psychiatric tools
ANNUAL PSYCHIATRY BUNDLE
Psychiatric MSE
AIMS
Diagnosis
Order Connect
Medication Service Plan
If applicable any new psychiatric tools
3. The frequency and duration of medication management services will be based
on the client's current needs according to MHP guidelines, including medical
necessity requirements and client goals in accordance with his/her Medication
Service Plan and client choice.
D. CONTRACTOR shall ensure continuity in medication support services until client is
linked with an appropriate service.
E. CONTRACTOR shall ensure that all appointments for medication support services
are adequately covered with utilization of the following resources if for any reason
the psychiatrist of record becomes unavailable.
F. CONTRACTOR will ensure clients with urgent medication needs can be seen
timely, including the availability for walk-in, and/or crisis service as clinically
appropriate.
G. CONTRACTOR shall conduct psychiatric assessments, perform mental status
examinations and formulate diagnoses of clients being treated at the adult mental
health locations.
H. CONTRACTOR shall provide psychiatric testimony in Court when and where
necessary, with the exception of LPS Conservatorship and Forensic or Incarcerated
cases.
I. CONTRACTOR shall complete medical record documentation as required by
COUNTY’s DBH Policy and Procedures.
Exhibit A
Page 8 of 11
J. CONTRACTOR shall provide supervision to Psychiatry Residents assigned to the
COUNTY’s locations.
K. CONTRACTOR shall ensure adequate supervision of mid-level practitioners.
L. CONTRACTOR shall perform administrative functions requiring psychiatry
staff and/or MD licensure, including but not limited to, review of inpatient
denials, participation in COUNTY DBH Credentialing Committee, review of
data and reports related to prescribing practices, quality assurance practices for
medical team, and other functions as mutually agreed by COUNTY and
CONTRACTOR.
M. CONTRACTOR shall provide an onsite Medical Director to provide onsite
supervision (clinical and administrative) to all of CONTRACTOR’s staff.
Medical Director shall:
1. Provide clinical and administrative supervision.
2. Ensure all CONTRACTOR’s staff follow applicable policy and procedures
as required by COUNTY’s DBH.
3. Provide regular coordination with the Chief of the Department of Psychiatry
regarding staffing, periodic training, updating health requirements (as
mandated by an affiliated medical education program and County DBH),
performance and disciplinary issues related to physicians for the intent of
providing consistent quality of clinical care and training to meet the standards
set forth by affiliated medical education program (e.g., UCSF Fresno).
4. Coordinate with an affiliated medical education program (e.g., UCSF Fresno
on the training of Psychiatry Residents.
5. Collaborate with COUNTY DBH’s Leadership Team in all matters of clinical
operations.
III. ADDITIONAL PROVISIONS :
A. CONTRACTOR shall:
1. Notify the COUNTY in writing or email 30 days prior to making any staffing
modifications to the staff assignments designated for each program/site
location listed in Section I above.
2. Receive written approval from the COUNTY prior to making any changes to
staffing and/or services rendered.
3. Ensure that all child psychiatry staff remain in good standing with American
Board of Psychiatry and Neurology.
Exhibit A
Page 9 of 11
4. Ensure that adult psychiatry staff and adult psychology staff shall adhere to
the rules and regulations as well as bylaws that govern COUNTY staff.
CHILD AND ADOLESCENT PSYCHIATRIC SERVICES
(County-Operated Clinic)
I. SERVICE LOCATION(S):
Facility Name: Heritage Center
Street Address: 3133 N. Millbrook Ave
City and Zip Code: Fresno, CA 93703
The above service location is COUNTY’s current service location, and the COUNTY, over the
duration of this Agreement, may add or change service locations.
II. SERVICE REOUIREMENTS :
A. CONTRACTOR shall provide integrated medication support services of co-
occurring mental health and substance use disorder services, in accordance with
MHP specialty mental health services requirements and documentation
standards.
B. COUNTY will provide appropriate billing and documentation training.
C. CONTRACTOR shall assess and provide outpatient psychiatric treatment for
children and adolescents who have been referred to COUNTY DBH.
D. CONTRACTOR shall provide medication support services and in accordance
with COUNTY policies, and include the following treatment strategies:
1. Medication Evaluation and Monitoring: CONTRACTOR shall offer medication
evaluation and monitoring to each client when clinically indicated. Medication
services will be provided individually. CONTRACTOR shall provide not less
than fifteen minutes of medication services for all clients within the clinically
appropriate timeframe, but not less than three times per year if stable. Clients
who are stable and maintain higher level of recovery shall be transitioned when
appropriate to outside providers.
2. Psychiatrists and/or other members of the medical team will complete the Initial
Psychiatric Assessment at the start of psychiatric service, and the Medication
Service Plan (Avatar CWS) at the start of service, and annually thereafter. All
signature/co-signature requirements must be completed in accordance with
COUNTY DBH policy.
INITIAL PSYCHIATRY BUNDLE
Exhibit A
Page 10 of 11
Initial Psychiatric Assessment
Psychiatric MSE
AIMS
Diagnosis
Order Connect
Medication Service Plan
If applicable any new psychiatric tools
ANNUAL PSYCHIATRY BUNDLE
Psychiatric MSE
AIMS
Diagnosis
Order Connect
Medication Service Plan
If applicable any new psychiatric tools
3. The frequency and duration of medication management services will be based
on the client's current needs and goals in accordance with his/her plan and
client choice.
E. CONTRACTOR shall ensure continuity in medication support services until client is
linked with an appropriate service.
F. CONTRACTOR shall ensure that all appointments for medication support services
are adequately covered if for any reason the psychiatrist of record becomes
unavailable.
G. CONTRACTOR will ensure clients with urgent medication needs can be seen
timely, including the availability for walk-in, and/or crisis service as clinically
appropriate.
H. CONTRACTOR shall complete medical record documentation as required by
COUNTY’s DBH Policy and Procedures.
I. CONTRACTOR shall provide supervision to Psychiatry Residents assigned to the
COUNTY’s locations.
J. CONTRACTOR shall ensure adequate supervision of mid-level practitioners.
K. CONTRACTOR shall perform administrative functions requiring psychiatry staff
and/or MD licensure, including but not limited to, review of inpatient denials,
Exhibit A
Page 11 of 11
participation in COUNTY DBH Credentialing Committee, review of data and
reports related to the prescribing practices, quality assurance practices for medical
team, and other functions as mutually agreed by COUNTY and CONTRACTOR.
L. CONTRACTOR shall dutifully assess and provide treatment to clients being
served as deemed medically necessary.
M. CONTRACTOR shall provide appropriate documentation meeting utilization review
requirements approved by COUNTY. For child psychiatry staff, this will include
meeting guidelines for documentation of vital statistics, laboratory work, medication
service plans, medication consents and other appropriate documentation as
determined by COUNTY.
N. CONTRACTOR shall coordinate with the Fresno County DBH Medical
Director with regards to medical and psychiatric issues related to the care and
treatment of clients at the Children’s Mental Health location.
III. ADDITIONAL PROVISIONS :
A. CONTRACTOR shall:
1. Notify the COUNTY in writing or email 30 days prior to making any staffing
modifications to the staff assignments designated for each program/site
location listed in Section I above.
2. Receive written approval from the COUNTY prior to making any changes to
staffing and/or services rendered.
3. Ensure that all child psychiatry staff remain in good standing with American
Board of Psychiatry and Neurology.
4. Ensure that child psychiatry staff and child psychology staff shall adhere to
the rules and regulations as well as bylaws that govern COUNTY staff.
Exhibit B
Page 1 of 12
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Medical Director 1.00 $80,625 $0 $80,625
0002 Assistant to Medical Director 1.00 $10,000 $0 $10,000
SALARY TOTAL 2.00 $90,625 $0 $90,625
PAYROLL TAXES:
0030 OASDI $562 $0 $562
0031 FICA/MEDICARE $1,314 $0 $1,314
0032 SUI $574 $0 $574
PAYROLL TAX TOTAL $2,450 $0 $2,450
EMPLOYEE BENEFITS:
0040 Malpractice $896 $0 $896
0041 Retirement $3,119 $0 $3,119
0042 Workers Compensation $743 $0 $743
0043 Health Insurance (medical, vision, life, dental, disabil.)$2,951 $0 $2,951
EMPLOYEE BENEFITS TOTAL $7,709 $0 $7,709
SALARY & BENEFITS GRAND TOTAL $100,784
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $0
OPERATING EXPENSES:
1060 Telephone/Paging $210
1061 Answering Service $0
1062 Postage $0
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $0
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $0
1075 Lodging $3,100
1076 Recruiting $184,200
1077 Other - Airfare $1,300
Line Item Description (Must be itemized)
CCFMG
Ramp-Up (May 1, 2018 - June 30, 2018)
Budget Categories - Total Proposed Budget
Exhibit B
Page 2 of 12
CCFMG
Ramp-Up (May 1, 2018 - June 30, 2018)
1078 Other - Rental Car $800
OPERATING EXPENSES TOTAL $189,610
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $43,859
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $43,859
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $2,000
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $2,000
TOTAL PROGRAM EXPENSES $336,253
Exhibit B
Page 3 of 12
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Medical Director 1.00 $387,000 $43,000 $430,000
0002 Assistant to Medical Director 1.00 $60,000 $0 $60,000
0003 Chief Child Psychiatrist 0.50 $85,000 $85,000 $170,000
0004 Adult/Child Psychiatrist 1.00 $0 $320,000 $320,000
0005 Adult/Child Psychiatrist 1.00 $0 $320,000 $320,000
0006 Adult/Child Psychiatrist 1.00 $0 $320,000 $320,000
0007 Adult/Child Psychiatrist 1.00 $0 $320,000 $320,000
0008 Adult/Child Psychiatrist 1.00 $0 $320,000 $320,000
0009 Compensation Incentive (productivity & quality)$0 $320,000 $320,000
0010 Retention Bonus $0 $50,000 $50,000
SALARY TOTAL 7.50 $532,000 $2,098,000 $2,630,000
PAYROLL TAXES:
0030 OASDI $15,661 $43,784 $59,446
0031 FICA/MEDICARE $7,714.00 $30,421.00 $38,135
0032 SUI $718 $1,579 $2,296
PAYROLL TAX TOTAL $24,093 $75,784 $99,877
EMPLOYEE BENEFITS:
0040 Malpractice $7,167 $26,279 $33,446
0041 Retirement $18,360 $62,940 $81,300
0042 Workers Compensation $4,362 $17,204 $21,566
0043 Health Insurance (medical, vision, life, dental, disabil.)$20,955 $47,685 $68,640
EMPLOYEE BENEFITS TOTAL $50,844 $154,108 $204,952
SALARY & BENEFITS GRAND TOTAL $2,934,829
FACILITIES/EQUIPMENT EXPENSES:
FACILITY/EQUIPMENT TOTAL $0
OPERATING EXPENSES:
1060 Telephone $10,080
1061 Answering Service $0
1062 Postage $0
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $0
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $0
1075 Lodging $6,000
1076 Recruiting $419,300
1077 Other - Airfare $3,200
Line Item Description (Must be itemized)
CCFMG
Operational (July 1, 2018 - June 30, 2019)
Budget Categories - Total Proposed Budget
Exhibit B
Page 4 of 12
CCFMG
Operational (July 1, 2018 - June 30, 2019)
1078 Other - Rental Car $1,600
OPERATING EXPENSES TOTAL $440,180
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $506,251
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $506,251
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $3,881,260
Exhibit B
Page 5 of 12
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Medical Director 1.00 $395,398 $43,933 $439,331
0002 Assistant to Medical Director 1.00 $61,302 $0 $61,302
0003 Chief Child Psychiatrist 0.50 $86,845 $86,844 $173,689
0004 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0005 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0006 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0007 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0008 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0009 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0010 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0011 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0012 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0013 Adult/Child Psychiatrist 1.00 $0 $326,944 $326,944
0014 Compensation Incentive (productivity & quality)$0 $640,000 $640,000
0015 Retention Bonus $0 $100,000 $100,000
SALARY TOTAL 12.50 $543,545 $4,140,217 $4,683,762
PAYROLL TAXES:
0030 OASDI $15,742 $83,588 $99,330
0031 FICA/MEDICARE $7,881 $60,033 $67,915
0032 SUI $718 $3,014 $3,731
PAYROLL TAX TOTAL $24,341 $146,635 $170,976
EMPLOYEE BENEFITS:
0040 Malpractice $7,167 $50,169 $57,336
0041 Retirement $18,758 $124,207 $142,965
0042 Workers Compensation $4,457 $33,950 $38,407
0043 Health Insurance (medical, vision, life, dental, disabil.)$20,955 $91,035 $111,990
EMPLOYEE BENEFITS TOTAL $51,338 $299,360 $350,698
SALARY & BENEFITS GRAND TOTAL $5,205,436
FACILITIES/EQUIPMENT EXPENSES:
FACILITY/EQUIPMENT TOTAL $0
OPERATING EXPENSES:
1060 Telephone $14,280
1061 Answering Service $0
1062 Postage $0
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $0
Line Item Description (Must be itemized)
CCFMG
Operational (July 1, 2019 - June 30, 2020)
Budget Categories - Total Proposed Budget
Exhibit B
Page 6 of 12
CCFMG
Operational (July 1, 2019 - June 30, 2020)
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $0
1075 Lodging $6,000
1076 Recruiting $419,300
1077 Other - Airfare $3,200
1078 Other - Rental Car $1,600
OPERATING EXPENSES TOTAL $444,380
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $847,472
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $847,472
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $6,497,288
Exhibit B
Page 7 of 12
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Medical Director 1.00 $403,978 $44,886 $448,864
0002 Assistant to Medical Director 1.00 $62,632 $0 $62,632
0003 Chief Child Psychiatrist 0.50 $88,729 $88,729 $177,458
0004 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0005 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0006 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0007 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0008 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0009 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0010 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0011 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0012 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0013 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0014 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0015 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0016 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0017 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0018 Adult/Child Psychiatrist 1.00 $0 $334,039 $334,039
0019 Compensation Incentive (productivity & quality)$0 $1,088,000 $1,088,000
0020 Retention Bonus $0 $170,000 $170,000
SALARY TOTAL 17.50 $555,339 $6,402,200 $6,957,539
PAYROLL TAXES:
0030 OASDI $15,824 $123,392 $139,217
0031 FICA/MEDICARE $8,052 $92,832 $100,884
0032 SUI $718 $5,023 $5,740
PAYROLL TAX TOTAL $24,594 $221,247 $245,841
EMPLOYEE BENEFITS:
0040 Malpractice $7,167 $74,059 $81,226
0041 Retirement $19,165 $192,066 $211,231
0042 Workers Compensation $4,554 $52,498 $57,052
0043 Health Insurance (medical, vision, life, dental, disabil.)$20,955 $134,385 $155,340
EMPLOYEE BENEFITS TOTAL $51,841 $453,008 $504,849
SALARY & BENEFITS GRAND TOTAL $7,708,229
FACILITIES/EQUIPMENT EXPENSES:
FACILITY/EQUIPMENT TOTAL $0
OPERATING EXPENSES:
1060 Telephone $20,160
1061 Answering Service $0
1062 Postage $0
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
Line Item Description (Must be itemized)
CCFMG
Operational (July 1, 2020 - June 30, 2021)
Budget Categories - Total Proposed Budget
Exhibit B
Page 8 of 12
CCFMG
Operational (July 1, 2020 - June 30, 2021)
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $0
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $0
1075 Lodging $6,000
1076 Recruiting $509,300
1077 Other - Airfare $3,200
1078 Other - Rental Car $1,600
OPERATING EXPENSES TOTAL $540,260
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $1,237,273
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $1,237,273
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $9,485,763
Exhibit B
Page 9 of 12
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Medical Director 1.00 $412,744 $45,860 $458,604
0002 Assistant to Medical Director 1.00 $63,991 $0 $63,991
0003 Chief Child Psychiatrist 0.50 $90,655 $90,654 $181,309
0004 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0005 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0006 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0007 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0008 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0009 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0010 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0011 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0012 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0013 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0014 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0015 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0016 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0017 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0018 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0019 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0020 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0021 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0022 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0023 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0024 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0025 Adult/Child Psychiatrist 1.00 $0 $341,287 $341,287
0026 Compensation Incentive (productivity & quality)$0 $1,600,000 $1,600,000
0027 Retention Bonus $0 $200,000 $200,000
SALARY TOTAL 24.50 $567,390 $9,444,836 $10,012,225
PAYROLL TAXES:
0030 OASDI $15,909 $179,118 $195,027
0031 FICA/MEDICARE $8,227 $136,950 $145,177
0032 SUI $718 $6,458 $7,175
PAYROLL TAX TOTAL $24,853 $322,526 $347,379
EMPLOYEE BENEFITS:
0040 Malpractice $7,167 $107,505 $114,672
0041 Retirement $19,581 $283,345 $302,926
0042 Workers Compensation $4,653 $77,448 $82,100
0043 Health Insurance (medical, vision, life, dental, disabil.)$20,955 $195,075 $216,030
EMPLOYEE BENEFITS TOTAL $52,356 $663,373 $715,729
SALARY & BENEFITS GRAND TOTAL $11,075,333
FACILITIES/EQUIPMENT EXPENSES:
FACILITY/EQUIPMENT TOTAL $0
OPERATING EXPENSES:
1060 Telephone $22,680
Line Item Description (Must be itemized)
CCFMG
Operational (July 1, 2021 - June 30, 2022)
Budget Categories - Total Proposed Budget
Exhibit B
Page 10 of 12
CCFMG
Operational (July 1, 2021 - June 30, 2022)
1061 Answering Service $0
1062 Postage $0
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $0
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $0
1075 Lodging $6,000
1076 Recruiting $329,300
1077 Other - Airfare $3,200
1078 Other - Rental Car $1,600
OPERATING EXPENSES TOTAL $362,780
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $1,715,717
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $1,715,717
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $13,153,830
Exhibit B
Page 11 of 12
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Medical Director 1.00 $421,700 $46,856 $468,556
0002 Assistant to Medical Director 1.00 $65,380 $0 $65,380
0003 Chief Child Psychiatrist 0.50 $92,622 $92,622 $185,244
0004 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0005 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0006 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0007 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0008 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0009 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0010 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0011 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0012 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0013 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0014 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0015 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0016 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0017 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0018 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0019 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0020 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0021 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0022 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0023 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0024 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0025 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0026 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0027 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0028 Adult/Child Psychiatrist 1.00 $0 $348,693 $348,693
0029 Compensation Incentive (productivity & quality)$0 $1,600,000 $1,600,000
0030 Retention Bonus $0 $150,000 $150,000
SALARY TOTAL 27.50 $579,702 $10,606,803 $11,186,505
PAYROLL TAXES:
0030 OASDI $15,995 $203,000 $218,995
0031 FICA/MEDICARE $8,406 $153,799 $162,204
0032 SUI $718 $7,319 $8,036
PAYROLL TAX TOTAL $25,118 $364,118 $389,235
EMPLOYEE BENEFITS:
0040 Malpractice $7,167 $121,839 $129,006
0041 Retirement $20,006 $318,204 $338,210
0042 Workers Compensation $4,754 $86,976 $91,729
0043 Health Insurance (medical, vision, life, dental, disabil.)$20,955 $221,085 $242,040
EMPLOYEE BENEFITS TOTAL $52,882 $748,104 $800,986
SALARY & BENEFITS GRAND TOTAL $12,376,726
FACILITIES/EQUIPMENT EXPENSES:
Line Item Description (Must be itemized)
CCFMG
Operational (July 1, 2022 - June 30, 2023)
Budget Categories - Total Proposed Budget
Exhibit B
Page 12 of 12
CCFMG
Operational (July 1, 2022 - June 30, 2023)
FACILITY/EQUIPMENT TOTAL $0
OPERATING EXPENSES:
1060 Telephone $22,680
1061 Answering Service $0
1062 Postage $0
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $0
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $0
1075 Lodging $6,000
1076 Recruiting $194,300
1077 Other - Airfare $3,200
1078 Other - Rental Car $1,600
OPERATING EXPENSES TOTAL $227,780
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $1,890,676
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $1,890,676
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $14,495,182
Exhibit C
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 subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor 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, consumers, 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 C
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 C
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 D
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.
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 five axis diagnosis from the most current DSM, 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:
Exhibit D
Page 2 of 3
• have specific observable and/or specific quantifiable goals
• 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
Exhibit D
Page 3 of 3
• 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
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 E
Page 1 of 2
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,
Exhibit E
Page 2 of 2
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of 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
Exhibit F
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
GGRRIIEEVVAANNCCEESS AANNDD IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
Exhibit F
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit G
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 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 G
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 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit H
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 H
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 I
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 I
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) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit J
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”), members
of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must disclose any
self-dealing transactions that they are a party to while providing goods, performing services, or both
for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit J
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: