HomeMy WebLinkAboutAgreement A-18-293 with Youth Treatment Services.pdf1
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AGREEMENT
THIS AGREEMENT is made and entered into this 5th
Agreement No. 18-293
day of _ __,J.,..u ..... n.._e ___ , 2018, by
3 and between the COUNTY OF FRESNO, a political subdivision of the State of California, hereinafter
4 referred to as "COUNTY," and each Provider listed in Exhibit A., "Youth Treatment Services Provider
5 List," attached hereto and by reference incorporated herein, collectively hereinafter referred to as
6 "PROVIDER," and such additional PROVIDER as may, from time to time during the term of this
7 Agreement, be added by COUNTY. Reference in this Agreement to "party" or "parties shall be
8 understood to refer to COUNTY and each PROVIDER, unless otherwise specified.
9 WHEREAS, COUNTY, through its Department of Behavioral Health, Contracts Division -
10 Substance Use Disorder Services (DBH), has determined there is a need for certain Fresno County
11 residents to receive outpatient drug free alcohol and substance use disorder services and dual
12 diagnosis mental health outpatient services; and
13 WHEREAS, COUNTY is authorized to contract with privately operated agencies for the
14 provision of non-Drug Medi-Cal alcohol and substance use disorder treatment services to Fresno
15 County minors between the ages of 12 and 17 years old and adults aged 18 years old receiving school-
16 based treatment, pursuant to both Title 9 and 22 of the California Code of Regulations, California
17 Health and Safety Code Sections 11750 et seq., the California Alcohol and Drug Standards and per the
18 terms and conditions of this agreement; and.
19 WHEREAS, PROVIDER is willing and able to provide these services required by COUNTY,
20 pursuant to the terms and conditions of this Agreement.
21 NOW, THEREFORE, in consideration of their mutual promises, covenants and conditions,
22 hereinafter set forth, the sufficiency of which is acknowledged, the parties agree as follows:
23 1. SERVICES
24 A. PROVIDER shall perform all services and fulfill all responsibilities for the
25 provision of outpatient SUD youth treatment services, as identified in this Agreement, including all
26 Exhibits, COUNTY's Request for Statement of Qualifications (RFSQ) # 18-024, dated January 17, 2018
27 . and Addendum No. One (1) dated February 1, 2018, herein after referred to as COUNTY Revised
28 RFSQ # 18-024, all incorporated herein by reference and made part of this Agreement.
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B. PROVIDER shall align program, services and practices with the vision and
mission of DBH as described in the Guiding Principles of Care Delivery, attached hereto as Exhibit B
and incorporated herein by reference.
C. In the event of any inconsistency among these documents, the inconsistency
shall be resolved by giving precedence in the following order of priority: 1) to this Agreement, including
any Exhibits and Amendments attached hereto; 2) to the revised RFSQ # 18-024; and 3) to the
Responses to the RFSQ. A copy of COUNTY’s Revised RFSQ #18-024 and PROVIDERS response
shall be retained and made available during the term of this Agreement by COUNTY’s Purchasing
Division.
D. PROVIDER’s administrative level agency representative, who is duly authorized
to act on behalf of the PROVIDER, must attend regularly scheduled PROVIDER meetings.
E. PROVIDER shall maintain at PROVIDER’s expense, a computer system
compatible with COUNTY’s Substance Abuse Information System (SAIS), and high-speed Internet
connection for the purposes of submitting information required under the terms and conditions of this
Agreement.
F. COUNTY encourages PROVIDER to adopt and maintain Electronic Health
Records (EHR) meeting the requirements of the Health Information Technology for Economic and
Clinical Health Act (HITECH), part of the American Recovery and Reinvestment Act (ARRA) of 2009.
PROVIDER shall bear the costs associated with penalties and/or fines for non-compliance with such
regulations.
2. TERM
The term of this Agreement shall be for a period of three (3) years, commencing on the
1st day of July, 2018 through the 30th of June, 2021. This Agreement may be extended for two (2)
additional twelve (12) month periods upon written approval of both parties no later than thirty (30) days
prior to the first day of each twelve (12) month period. The DBH Director, or her designee, is authorized
to execute such written approval on behalf of the COUNTY based on PROVIDER’s satisfactory
performance.
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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 the funds by the appropriating government
agency. Should insufficient funds not be allocated, the services may be modified, or this Agreement
terminated, at any time by giving the PROVIDER thirty (30) days advance notice.
B. BREACH OF CONTRACT – COUNTY may immediately suspend or terminate
this Agreement in whole or in part, where in the determination of the COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term in this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4) Improperly performed service.
In no event shall any payment by the COUNTY constitute a waiver by COUNTY of any
breach of this Agreement or any default which may then exist on the part of the PROVIDER. Neither
shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or
default. COUNTY shall have the right to demand of the PROVIDER the repayment to COUNTY of any
funds disbursed to the PROVIDER under this Agreement. The PROVIDER shall promptly refund any
such funds upon demand.
C. WITHOUT CAUSE – Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY or PROVIDER upon giving thirty (30) days advance written
notice.
4. COMPENSATION
A. COMPENSATION – For claims submitted for services rendered under this
Agreement, COUNTY agrees to pay PROVIDER and PROVIDER agrees to receive compensation for
costs associated with the delivery of outpatient SUD services provided by PROVIDER in accordance
with the State-set ”Proposed Drug Medi-Cal Rates for Fiscal Year 2018-19,” attached hereto as Exhibit
C and by this reference incorporated herein, and updated annually, for each term of this Agreement. It
is understood that all expenses incidental to PROVIDER’S performance of services under this
Agreement shall be borne by PROVIDER. In no event shall the total compensation for actual service
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performed under this Agreement be in excess of One Million Dollars ($1,000,000.00) for each twelve
(12) month period from July 1, 2018 through June 30, 2023 and Providers Annual Contract Maximum in
accordance with Exhibit A, Youth Treatment Services Provider List. PROVIDER shall be reimbursed to
the extent that funds are available.
B. The contract maximum amount identified in this Agreement may be reduced
based upon State, Federal, and local funding availability. In the event of such action, the COUNTY’s
DBH Director or her designee shall notify the PROVIDER in writing of the reduction in the maximum
amount within thirty (30) days.
In the event that funding for these services is delayed by the State Controller,
COUNTY may defer payment to PROVIDER. The amount of the deferred payment shall not exceed the
amount of funding delayed by the State Controller to the COUNTY. 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. In addition, if the State of California does not allocate funding for services described in the terms
and conditions of this Agreement, DBH-SUD Services shall not be obligated to reimburse PROVIDER
for services performed.
C. PAYMENTS – Regardless of the contract maximum, PROVIDER will be
reimbursed only for costs up to the set DMC rates herein. Within forty-five (45) days of the
reconciliation by COUNTY, PROVIDER shall make payment to COUNTY or COUNTY shall reimburse
PROVIDER as appropriate.
Payment by COUNTY shall be in arrears, based on PROVIDER’s monthly
invoices submitted for services provided during the preceding month, within forty-five (45) days after
receipt and verification of PROVIDER’s monthly invoices by COUNTY’s DBH, Contracts Division-SUD
Services.
D. QUALITY ASSURANCE – For services rendered herein, PROVIDER shall
assure that an on-going quality assurance component is in place and is occurring. PROVIDER shall
assure that clinical records for each participant are of such detail and length that a review of said record
will verify that appropriate services were provided. If the record is unclear, incomplete, and/or indicates
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that appropriate services were not provided, COUNTY reserves the right to withhold payment for the
applicable unit(s) of service.
E. COMPLIANCE – If PROVIDER should fail to comply with any provision of this
Agreement, COUNTY shall be relieved of its obligation for further compensation. PROVIDER’s and
COUNTY’s obligations under this section shall survive the termination of this Agreement with respect to
services provided during the term of this Agreement without regard to the cause of termination of this
Agreement.
F. PUBLIC INFORMATION – PROVIDER shall disclose its funding source in all
public information; however, this requirement of disclosure of funding source shall not be required in
spot radio or television advertising.
G. LOBBYING ACTIVITY – PROVIDER shall not directly or indirectly use any of the
funds under the Agreement for any political activity or to further the election or defeat of any candidate
for public office.
H. FUNDING SOURCES – It shall be the obligation of PROVIDER to determine and
claim all revenue possible from private pay sources and third party payers. PROVIDER shall not use
any funding under this Agreement for services covered by Drug Medi-Cal or other health insurance for
eligible beneficiaries. PROVIDER shall claim all Drug Medi-Cal covered services for eligible
beneficiaries through the Drug Medi-Cal claiming process. PROVIDER with a Youth Treatment contract
with the County must bill services for DMC-ineligible adolescents to the Youth Treatment contract.
COUNTY will only reimburse PROVIDER for services rendered that are not covered by Drug Medi-Cal,
other insurance or other revenue sources.
PROVIDER shall not use any funds under this Agreement to the extent that a
participant is eligible for Drug Medi-Cal, insurance or other revenue reimbursement for services
rendered.
Any revenues generated by PROVIDER is excess of the amounts budgeted in
this Agreement may be utilized to expand/enhance the services during COUNTY’s fiscal years in which
revenues are collected or in the following COUNTY fiscal year. Additional revenues will be considered
separate and distinct from COUNTY’s payment to PROVIDER. The manner and means of service
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expansion/enhancement shall be subject to the prior written approval of COUNTY’s DBH Director or
her designee. PROVIDER shall disclose all sources of revenue to COUNTY. Under no circumstances
will COUNTY funded staff time be used for fund-raising purposes.
5. INVOICING
PROVIDER shall invoice COUNTY in arrears by the (20th) day of each month for actual
services rendered in the previous month. Invoices shall be emailed to SAS@co.fresno.ca.us with the
subject line “Youth Treatment Services Analyst.” Invoices shall be accompanied by monthly client roster
indicating units of service, documentation of DMC and other Health Care coverage ineligibility and other
documentation and reports as indicated in Section Sixteen (16), REPORTS – SUBSTANCE USE
DISORDER SERVICES. Any reports or other required documentation shall be in the form and in such
detail as acceptable to COUNTY’s DBH. No reimbursement for services shall be made until the invoice
is received, reviewed, and approved by COUNTY’s DBH.
If an invoice is incorrect or is otherwise not in proper form or substance, COUNTY’s DBH
Director or her designee shall have the right to withhold payment as to only that portion of the invoice
that is incorrect or improper after five (5) days prior to notice to PROVIDER. PROVIDER agrees to
continue to provide services for a period of ninety (90) days after notification of an incorrect or improper
invoice. If after said ninety (90) day period said invoice(s) is still not corrected to the satisfaction of
COUNTY’s DBH Director, COUNTY may elect to terminate the Agreement, pursuant Section Three (3),
TERMINATION, of this Agreement. In addition, PROVIDER shall submit all invoices to COUNTY’s DBH
for services provided within ninety (90) days after each 12 month period of this Agreement expires or
this Agreement is terminated. If invoices are not submitted within ninety (90) days after each 12 month
period expires or this Agreement is terminated, COUNTY’s DBH shall have the right to deny payment.
Final general ledgers for services provided during each 12 month period of this
Agreement must be received within sixty (60) days after each 12 month period expires or this
Agreement is terminated, COUNTY’s DBH shall have the right to deny payment for services covered by
such general ledger.
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6. PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for PROVIDER’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), SERVICES, of this Agreement shall be
allowed as necessary to raise public awareness about the availability of such specific services when
approved in advance by the DBH Director or her designee, and at a cost provided for such items as
written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related
expense(s).
7. INDEPENDENT CONTRACTOR
In performance of the work, duties and obligations assumed by PROVIDER under this
agreement, it is mutually understood and agreed that PROVIDER, including any and all of the
PROVIDER’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 venture, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no
right to control or supervise, or direct the manner or method by which PROVIDER shall perform its work
and function. However, COUNTY shall retain the right to administer the Agreement so as to verify that
PROVIDER is performing its obligations in accordance with the terms and conditions thereof.
PROVIDER and COUNTY shall comply with all applicable provisions of law and the
rules and regulations, if any, of governmental authorities having jurisdiction over matters the subject
thereof.
Because of its status as an independent contractor, PROVIDER shall have absolutely no right to
employment rights and benefits available to COUNTY employees. PROVIDER shall be solely liable and
responsible for providing to, or on behalf of, its employees all legally-required employee benefits. In
addition, PROVIDER shall be solely responsible to save COUNTY harmless from all matters relating to
payment of PROVIDER’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,
PROVIDER may be providing services to others unrelated to the COUNTY or to the Agreement.
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8. CONFLICT OF INTEREST
No officer, agent, or employee of the COUNTY who exercises any function or
responsibility for planning and carrying out the services provided under this Agreement shall have any
direct or indirect personal financial interest in this Agreement. PROVIDER shall comply with all Federal,
State of California, and local conflict of interest laws, statutes, and regulations, which shall be
applicable to all parties and beneficiaries under this Agreement and any officer, agent, or employee of
the COUNTY.
9. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the PROVIDER is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, the PROVIDER changes its
status to operate as a corporation.
Members of the PROVIDER’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while PROVIDER is providing goods or performing services under
this Agreement. A self-dealing transaction shall mean a transaction to which the PROVIDER is a party
and in which one or more of its directors has a material financial interest. Members of the Board of
Directors shall disclose any self-dealing transactions that they are a party to by completing and signing
a Self-Dealing Transaction Disclosure Form (Exhibit D) and submitting it to the COUNTY prior to
commencing with the self-dealing transaction or immediately thereafter.
10. MODIFICATION
Any matters of this Agreement may be modified from time to time by written consent of
all parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to Section One (1), SERVICES, as needed to
accommodate changes in State and Federal Law relating to mental health and substance use disorder
treatment may be made with the signed written approval of COUNTY’s DBH Director or her designee
and respective PROVIDER(S) through an amendment approved by County Counsel and Auditor.
11. NON-ASSIGNMENT
Neither party shall assign, transfer or sub-contract this Agreement not their rights or
duties under this Agreement without prior written consent of the other party.
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12. HOLD HARMLESS
PROVIDER agrees to indemnify, save, hold harmless, and at COUNTY’s request,
defend the COUNTY, its officers, agents, and employees form any and all costs and expenses,
damages, liabilities, claims, and losses occurring or resulting to any person, firm, or corporation who
may be injured or damaged by the performance, or failure to perform, of PROVIDER, its officers,
agents, or employees under this Agreement.
PROVIDER agrees to indemnify COUNTY for Federal, State of California audit
exceptions resulting from noncompliance herein on the part of the PROVIDER.
13. INSURANCE
Without limiting the COUNTY’s right to obtain indemnification from PROVIDER or any
third parties, PROVIDER, at its sole expense, shall maintain in full force and effect, the following
insurance policies or a program of self-insurance, including but not limited to, an insurance pooling
arrangement or Joint Powers Agreement (JPA) throughout the term of the contract:
A. COMMERCIAL GENERAL LIABILITY
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars ($2,000,000). This
policy shall be issued on a per occurrence basis. COUNTY may require specific coverages including
completed operations, products liability, contractual liability, Explosion-Collapse-Underground, fire legal
liability or any other liability insurance deemed necessary because of the nature of this contract.
B. AUTOMOBILE LIABILITY
Comprehensive Automobile Liability Insurance with limits for bodily injury of not
less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred Thousand Dollars
($500,000.00) per accident and for property damages of not less than Fifty Thousand Dollars
($50,000.00), or such coverage with a combined single limit of Five Hundred Thousand Dollars
($500,000.00). Coverage should include owned and non-owned vehicles used in connection with this
Agreement.
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C. PROFESSIONAL LIABILITY
If PROVIDER employs licensed professional staff (e.g., Ph.D., R.N., L.C.S.W.,
L.M.F.T) in providing services, Professional Liability Insurance with limits of not less than One Million
Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate.
D. WORKERS COMPENSATION
A policy of Worker’s Compensation insurance as may be required by the
California Labor Code.
PROVIDER 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 PROVIDER’s policies herein. This
insurance shall not be cancelled or changed without a minimum of thirty (30) days advance notice given
to COUNTY.
Within thirty (30) days for the date PROVIDER signs this Agreement, PROVIDER
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, Contracts
Division – Substance Use Disorder Services at 3133 N. Millbrook Ave., Fresno California, 93703,
Attention: SUD Services Staff Analyst, stating that such Commercial General Liability insurance names
the County of Fresno, its officers, agents, employees, individually and collectively, as additional
insured, but 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 in excess only and not
contributing with insurance provided under PROVIDER’s policies herein; and that this insurance shall
not be cancelled or changed without minimum of thirty (30) days advance, written notice given to
COUNTY.
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In the event any PROVIDER 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 the Agreement with Provider 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.
E. CHILD ABUSE/MOLESTATION
Providers that deliver SUD outpatient or residential treatment who are pregnant
and/or parenting where the child(ren) are involved or present at treatment facilities or deliver SUD
treatment services to adolescents shall maintain Child Abuse/Molestation and Social Services liability
insurance of not less than One Million Dollars ($1,000,000) per occurrence with an annual aggregate of
Two Million ($2,000,000).
14. SUBCONTRACTS
PROVIDER shall be required to assume full responsibility for all services and activities
covered by this Agreement, whether or not PROVIDER is providing services directly. Further,
PROVIDER shall be the sole point of contact with regard to contractual matters, including payment of
any and all charges from the Agreement.
If PROVIDER should propose to subcontract with one or more third parties to carry out a
portion of the services covered by this Agreement, any such subcontract shall be in writing and
approved as to form and content by COUNTY’s DBH Director or her designee prior to execution and
implementation. COUNTY’s DBH Director or her designee shall have the right to reject any such
proposed subcontract. Any such subcontract together with all activities by or caused by PROVIDER
shall not require compensation greater than the total budget contained herein. An executed copy of any
such subcontract shall be received by COUNTY before any implementation and shall be retained by
COUNTY. PROVIDER shall be responsible to COUNTY for the proper performance of any subcontract.
Any subcontractor shall be subject to the same terms and conditions that PROVIDER is subject to
under this Agreement.
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15. NO THIRD PARTY BENEFICIARIES
It is understood and agreed by and between the parties that the services provided by
PROVIDER for COUNTY herein are solely for the benefit of the COUNTY, and that nothing in
Agreement is intended to confer on any person other that the parties hereto any right under or by
reason of this Agreement.
16. REPORTS—SUBSTANCE USE DISORDER SERVICES
PROVIDER(S) shall submit all information and data required by State, including, but not
limited to the following:
1) Drug and Alcohol Treatment Access Report (DATAR) and Provider
Waiting List Record (WLR) in an electronic format provided by the State and due no later than five (5)
days after the preceding month; and
2) CalOMS Treatment – Submit CalOMS treatment admission, discharge,
annual update, and “provider activity report” record in an electronic format through COUNTY’s SAIS
system, and on a schedule as determined by the COUNTY which complies with State requirements for
data content, data quality, reporting frequency, reporting deadlines, and report method and due no later
than five (5) days after the preceding month. All CalOMS admissions, discharges, and annual updates
must be entered into the COUNTY’s CalOMS system within twenty-four (24) hours of occurrence; and
3) PROVIDER(S) shall submit to COUNTY monthly fiscal and all program
reports, including Provider Waiting List Record (WLR), within twenty (20) days of the end of each
month.
4) Americans with Disabilities (ADA) – Annually, upon request by DBH,
PROVIDER(S) shall complete a system-wide accessibility survey in a format determined by DBH for
each service location and modality and shall submit an ADA Accessibility Certification and Self-
Assessment, including an Implementation Plan, for each service location.
5) Cost Reports – On an annual basis for each fiscal year ending June 30th
PROVIDER(S) shall submit a complete and accurate detailed cost report(s). Cost reports must be
submitted to the COUNTY as a hard copy with a signed cover letter and an electronic copy by the due
date. Submittal must also include any requested support documents such as general ledgers. All
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reports submitted by PROVIDER(S) to COUNTY must be typewritten. COUNTY will issue instructions
for completion and submittal of the annual cost report, including the relevant cost report template(s) and
due dates within forty-five (45) days of each fiscal year end. All cost reports must be prepared in
accordance with Generally Accepted Accounting Principles. Unallowable costs such as lobbying or
political donations must be deducted from the cost report and all invoices. If the PROVIDER(S) does
not submit the cost report by the due date, including any extension period granted by the COUNTY, the
COUNTY may withhold payment of pending invoices until the cost report(s) has been submitted and
clears COUNTY desk audit for completeness and accuracy.
A. DMC - A DMC cost report must be submitted in a format
prescribed by the DHCS for the purposes of Short Doyle Medi-Cal reimbursement of total costs for all
programs. PROVIDER(S) shall report costs under their approved legal entity number established during
the DMC certification process. Total units of service reported on the cost report will be compared to the
units of services entered by PROVIDER(S) into COUNTY’s data system. PROVIDER(S) will be
required to correct discrepancies and resubmit to COUNTY prior to COUNTY’s final acceptance of the
cost report.
B. OTHER FUNDING SOURCES – PROVIDER(S) will be required to
submit a cost report on a form(s) approved and provided by the COUNTY to reflect actual costs and
reimbursement for services provided through funding sources other than DMC. Contracts that include a
negotiated rate per unit of service will be reimbursed only for the costs of approved units of service up
to the negotiated unit of service rate approved in the Agreement, regardless of the contract maximum. If
the cost report indicates an amount due to COUNTY, PROVIDER(S) shall submit payment with the
report. If an amount is due to PROVIDER(S) COUNTY shall reimburse PROVIDER within forty-five (45)
days of receiving and accepting the year-end cost report.
C. MULTIPLE FUNDING SOURCES – PROVIDER(S) who has
multiple agreements for the same services provided at the same location where at least one of the
Agreements is funded through DMC and the other funding is other federal or county realignment
funding will be required to complete DMC cost reports and COUNTY approved cost reports. Such
Agreements will be settled for actual costs in accordance with Medicaid reimbursement requirements
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as specified in Title XIX or Title XXI of the Social Security Act; Title 22, and the State’s Medicaid Plan.
During the term of this Agreement and thereafter, COUNTY and PROVIDER(S) agree to settle dollar
amounts disallowed or settled in accordance with DHCS and COUNTY audit settlement findings. DHCS
audit process is approximately eighteen (18) to thirty-six (36) months following the close of the State
fiscal year. COUNTY may choose to appeal DHCS settlement results and therefore reserves the right
to defer payback settlement with PROVIDER(S) until resolution of the appeal.
In the event that PROVIDER(S) fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for the COUNTY to withhold monthly payments
until there is compliance. In addition, the PROVIDER shall provide written notification and explanation
to the COUNTY within fifteen (15) days of any funds received from another source to conduct the same
services covered by this Agreement.
17. EVALUATION – MONITORING
OUTCOMES – COUNTY’s DBH Director, or her designee, and DHCS or their designees
shall monitor and evaluate the performance of PROVIDER under this Agreement to determine to the
best possible degree the success or failure of the services provided under this Agreement. At the
discretion of the COUNTY, a subcontractor may be obtained by the COUNTY to independently
evaluate and monitor the performance of the PROVIDER. PROVIDER shall participate in the evaluation
of the program as needed, at the discretion of COUNTY.
COUNTY shall recapture from PROVIDER the value of any services or other
expenditures determined to be ineligible based on the COUNTY or State monitoring results. At the
discretion of the COUNTY, recoupment can be made through a future invoice reduction or
reimbursement by the PROVIDER.
PROVIDER shall participate in a review of the program at least yearly or more
frequently, or as needed, at the discretion of COUNTY. The PROVIDER agrees to supply all
information requested by the COUNTY, DHCS, and/or the subcontractor during the program evaluation,
monitoring, and/or review.
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18. 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 PROVIDER by the COUNTY, including but not limited to the following:
A. PROVIDER-OWNED MOBILE, WIRELESS, OR HANDHELD DEVICES
PROVIDER may not connect to COUNTY networks via personally-owned mobile,
wireless or handheld devices, unless the following conditions are met:
1) PROVIDER has received authorization by COUNTY for telecommuting
purposes;
2) Current virus protection software is in place;
3) Mobile device has the remote wipe feature enabled; and
4) A secure connection is used.
B. PROVIDER-OWNED COMPUTERS OR COMPUTER PERIPHERALS
PROVIDER may not bring PROVIDER-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
PROVIDER or anyone having an employment relationship with the COUNTY
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. PROVIDER may not store COUNTY’s private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
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E. PROVIDER 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. PROVIDER is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data
maintained in computer files, program documentation, data processing systems, data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to PROVIDER’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information provided
to PROVIDER. PROVIDER will be responsible to issue any notification to affected individuals as
required by law or as deemed necessary by COUNTY in its sole discretion. PROVIDER will be
responsible for all costs incurred as a result of providing the required notification.
19. YOUTH TREATMENT
PROVIDER shall follow the guidelines incorporated by this reference, "Youth Treatment
Guidelines," in staffing, developing and implementing youth treatment programs, until such time new
Youth Treatment Guidelines are established and adopted. No formal amendment of this contract is
required for new guidelines to apply as the Youth Treatment Guidelines are updated. Current Youth
Treatment Guidelines are available on the DHCS website at:
http://www.dhcs.ca.gov/individuals/Pages/youthSUDservices.aspx
20. INTERIM SERVICES
PROVIDER must adhere to the State-County Contract requirement to provide Interim
Services in the event that an individual must wait to be placed in treatment.
Interim Substance Abuse Services means services that are provided until an individual is
admitted to a substance abuse treatment program. The purposes of the services are to reduce the
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adverse health effects of such abuse, promote the health of the individual, and reduce the risk of
transmission of disease. At a minimum, interim services include counseling and education about HIV
and tuberculosis (TB), about the risks of needle-sharing, the risks of transmission to sexual partners
and infants, and about steps that can be taken to ensure the HIV and TB transmission does not occur,
as well as referral for HIV or TB treatment services if necessary. For pregnant women, interim services
also include counseling on the effects of alcohol and drug use on the fetus, as well as referral for
prenatal care.
Records must indicate evidence that Interim Services have been provided and
documentation will be reviewed for compliance.
21. 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.
22. STATE ALCOHOL AND DRUG REQUIREMENTS
A. INDEMNIFICATION
The PROVIDER agrees to indemnify, defend and save harmless the State, its
officers, agents and employees from any and all claims and losses accruing or resulting to any and all
contractors, subcontractors, materialmen, laborers and any other person, firm or corporation furnishing
or supplying work, services, materials or supplies in connection with the performance of this Agreement
and from any and all claims and losses accruing or resulting to any person, firm or corporation who may
be injured or damaged by the PROVIDER in the performance of this Agreement.
B. INDEPENDENT CONTRACTOR
The PROVIDER and the agents and employees of PROVIDER, in the
performance of this Agreement, shall act in an independent capacity and not as officers or employees
or agents of State of California.
C. CONTROL REQUIREMENTS
This Agreement is subject to all applicable Federal and State laws, regulations
and standards. PROVIDER(S) shall establish written procedures consistent with State-County Contract
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requirements. The provisions of this Agreement are not intended to abrogate any provisions of law or
regulation existing or enacted during the term of this Agreement.
D. CONFIDENTIALITY
PROVIDER 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 Part 2, Title 42, Code of Federal Regulations;
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.
E. REVENUE COLLECTION POLICY
PROVIDER shall conform to all policies and procedures regarding revenue
collection issued by the State under the provisions of the Health and Safety Code, Division 10.5.
F. EXPENDITURE OF STATE GENERAL AND FEDERAL FUNDS
PROVIDER agrees that all funds paid out by the State shall be used exclusively
for providing alcohol and/or drug program services, administrative costs, and allowable overhead.
G. ACCESS TO SERVICES
PROVIDER shall provide accessible and appropriate services in accordance with Federal
and State statutes and regulations to all eligible persons.
H. REPORTS
PROVIDER agrees to participate in surveys related to the performance of this Agreement and
expenditure of funds and agrees to provide any such information in a mutually agreed upon format.
I. AUDITS
All State and Federal funds furnished to the PROVIDER(S) pursuant to this
Agreement along with related patient fees, third party payments, or other related revenues and funds
commingled with the foregoing funds are subject to audit by the State. The State may audit all alcohol
and drug program revenue and expenditures contained in this Agreement for the purpose of
establishing the basis for the subsequent year's negotiation.
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J. RECORDS MAINTENANCE
1) PROVIDER shall maintain books, records, documents, and other
evidence necessary to monitor and audit this Agreement.
2) PROVIDER shall maintain adequate program and fiscal records relating
to individuals served under the terms of this Agreement, as required, to meet the needs of the State in
monitoring quality, quantity, fiscal accountability, and accessibility of services. Information on each
individual shall include, but not be limited to, admission records, patient and participant interviews and
progress notes, and records of service provided by various service locations, in sufficient detail to make
possible an evaluation of services provided and compliance with this Agreement.
23. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and PROVIDER each consider and represent themselves as covered entities
as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
191(HIPAA) and agree to use and disclose protected health information as required by law.
COUNTY and PROVIDER acknowledge that the exchange of protected health
information between them is only for treatment, payment, and health care operations.
COUNTY and PROVIDER intend to protect the privacy and provide for the security of
Protected Health Information (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
PROVIDER to enter into a contract containing specific requirements prior to the
disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and
164.504(e) of the Code of Federal Regulations (CFR).
24. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, PROVIDER shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
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from discriminating against persons based on race, color, national origin, sex, disability or religion. This
is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive and quality bilingual
services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP consumers, including, but not limited to,
assessing the cultural and linguistic needs of its consumers, training of staff on the policies and
procedures, and monitoring its language assistance program. The PROVIDER’s procedures must
include ensuring compliance of any sub-contracted providers with these requirements.
C. PROVIDER assurances that minors shall not be used as interpreters.
D. PROVIDER shall provide and pay for interpreting and translation services to
persons participating in PROVIDER’s services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be
provided as necessary to allow such participants meaningful access to the programs, services and
benefits provided by PROVIDER. Interpreter and translation services, including translation of
PROVIDER’s “vital documents” (those documents that contain information that is critical for accessing
PROVIDER’s services or are required by law) shall be provided to participants at no cost to the
participant. PROVIDER shall ensure that any employees, agents, subcontractors, or partners who
interpret or translate for a program participant, or who directly communicate with a program participant
in a language other than English, demonstrate proficiency in the participant's language and can
effectively communicate any specialized terms and concepts peculiar to PROVIDER’s services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, PROVIDER must submit to COUNTY
for approval, within 60 days from date of contract execution, PROVIDER’s plan to address all fifteen
national cultural competency standards as set forth in the “National Standards on Culturally and
Linguistically Appropriate Services” (CLAS), attached hereto as Exhibit E, and incorporated herein by
this reference. County’s annual on-site review of PROVIDER shall include collection of documentation
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to ensure all national standards are implemented. As the national competency standards are updated,
PROVIDER’s plan must be updated accordingly.
F. PROVIDER shall complete and submit county-issued CLAS self-assessment
annually. PROVIDER shall update CLAS plan as necessary.
25. SINGLE AUDIT CLAUSE
A. If PROVIDER expends Seven Hundred Fifty Thousand Dollars ($750,000.00) or
more in Federal and Federal flow-through monies, PROVIDER agrees to conduct an annual audit in
accordance with the requirements of the Single Audit Standards as set forth in 2CFR Part 200.
PROVIDER 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,
PROVIDER must include a corrective action plan signed by an authorized individual. PROVIDER
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 Department of Behavioral Health, Business Office
for review within nine (9) months of the end of any fiscal year in which funds were expended and/or
received for the program. Failure to perform the requisite audit functions as required by this Agreement
may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option, contracting with
a public accountant to perform said audit, or, may result in the inability of COUNTY to enter into future
agreements with PROVIDER. All audit costs related to this Agreement are the sole responsibility of
PROVIDER.
B. A single audit report is not applicable if PROVIDER’s Federal contracts do not
exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or PROVIDER’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 PROVIDER to
COUNTY as a minimum requirement to attest to PROVIDER’s solvency. Said audit report shall be
delivered to COUNTY’s Department of Behavioral Health, Business Office for review, no later than nine
(9) months after the close of the fiscal year in which the funds supplied through this Agreement are
expended. Failure to comply with this Act may result in COUNTY performing the necessary audit tasks
or contracting with a qualified accountant to perform said audit. All audit costs related to this
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Agreement are the sole responsibility of PROVIDER who agrees to take corrective action to eliminate
any material noncompliance or weakness found as a result of such audit. Audit work performed by
COUNTY under this section shall be billed to the PROVIDER at COUNTY’s cost, as determined by
COUNTY’s Auditor-Controller/Treasurer-Tax Collector.
PROVIDER 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.
26. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v) (1) 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, PROVIDER shall make available, upon
written request of the Secretary of the United States Department of Health and Human Services, or
upon request of 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 PROVIDER
under this Agreement. PROVIDER further agrees that in the event PROVIDER carries out any of its
duties under this Agreement through a subcontract, with a value or cost of Ten Thousand and No/100
Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such
Agreement shall contain a clause to the effect that until the expiration of four (4) years after the
furnishing of such services pursuant to such subcontract, the related organizations shall make
available, upon written request of the Secretary of the United States Department of Health and Human
Services, or upon request of 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.
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27. COMPLIANCE WITH LAWS AND POLICIES
PROVIDER shall comply with all applicable rules and regulations set forth in Titles 9 and
22 of the California Code of Regulations, and California Health and Safety Code section 11750 et seq.
PROVIDER shall comply with any other Federal and State laws or guidelines applicable to
PROVIDER’s performance under this Agreement or any local ordinances, regulations, or policies
applicable. Such provisions include, but are not restricted to:
A. PROVIDER shall provide that each client's ability to pay for services is
determined by the use of the method approved by COUNTY.
B. PROVIDER shall establish and use COUNTY’s approved method of determining
and collecting fees from clients.
C. PROVIDER shall furnish client records in accordance with the applicable Federal
and State regulations, and with the Standards for Alcohol and Drug Treatment Programs set forth by
the State Department of Alcohol and Drug Programs, including in such records a treatment plan for
each client, and evidence of each service rendered.
D. PROVIDER shall submit accurate, complete and timely claims and cost reports,
reporting only allowable costs.
E. PROVIDER shall comply with statistical reporting and program evaluation
systems as provided in State of California regulations and in this Agreement.
F. PROVIDER shall comply with requirements contained in the State-County
Contract with DHCS by this reference incorporated herein, until such time that a new State-County
Contract is established. Upon amendment of the State-County Contract, the terms of the amended
Contract shall automatically be incorporated into this Agreement.
28. FEDERAL CERTIFICATIONS
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS
A. DBH and PROVIDER recognize that Federal assistance funds will be used under
the terms of this Agreement. For purposes of this section, DBH will be referred to as the "prospective
recipient".
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B. This certification is required by the regulations implementing Executive Order
12549, Debarment and Suspension, 29 CFR Part 98, section 98.510, Participants' responsibilities. The
regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211).
1) The prospective recipient of Federal assistance funds certifies by entering
this Agreement, that neither it nor its principals are presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any
Federal department or agency.
2) The prospective recipient of funds agrees by entering into this
Agreement, that it shall not knowingly enter into any lower tier covered transaction with a person who is
debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the Federal department or agency with which this transaction
originated.
3) Where the prospective recipient of Federal assistance funds is unable to
certify to any of the statements in this certification, such prospective participant shall attach an
explanation to this Agreement.
4) The PROVIDER shall provide immediate written notice to DBH if at any
time PROVIDER learns that its certification in this clause of this Agreement was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5) The prospective recipient further agrees that by entering into this
Agreement, it will include a clause identical to this clause of this Agreement, and titled "Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered
Transactions", in all lower tier covered transactions and in all solicitations for lower tier covered
transactions.
6) The certification in this clause of this Agreement is a material
representation of fact upon which reliance was placed by COUNTY when this transaction was entered
into.
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29. CLEAN AIR AND WATER
In the event funding under this Agreement exceeds one hundred thousand dollars ($100,000.00),
the PROVIDER must comply with all applicable standards, orders, or requirements issued under
section 306 of the Clean Air Act (42 U.S.C. 1857 (h)), section 506 of the Clean Water Act (33 U.S.C.
1368), Executive Order 11738, and Environmental Protection Agency Regulations (40 CFR part 32).
30. SMOKING PROHIBITION REQUIREMENTS
PROVIDER shall comply with Public Law 103-227, also known as the Pro-Children Act of 1994
(20 USC Section 6081, et seq.), and with California Labor Code Section 6404.5, the California Smoke-
Free Workplace Law.
31. ENERGY EFFICIENCY
The PROVIDER must comply with the mandatory standards and policies relating to energy
efficiency which are contained in the state energy conservation plan issued in compliance with Energy
Policy and Conservation Act (Pub. L. 94 163).
32. NON-DISCRIMINATION PROVISION
A. ELIGIBILITY FOR SERVICES – PROVIDER shall prepare, prominently post in its
facility, and make available to the DBH Director or her designee and to the public all eligibility
requirements to participate in the program funded under this Agreement. PROVIDER shall not
unlawfully discriminate in the provision of services because of race, religious creed, color, national
origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital
status, sex, gender, gender identity, gender expression, age, sexual orientation, or military or veteran
status as provided by State of California and Federal law in accordance with Title VI of the Civil Rights
Act of 1964 (42 USC section 2000(d)); Age Discrimination Act of 1975 (42 USC section 1681);
Rehabilitation Act of 1973 (29 USC section 794); Education Amendments of 1972 (20 USC section
1681); Americans with Disabilities Act of 1990 (42 USC section 12132); Title 45, Code of Federal
Regulations, Part 84; provisions of the Fair Employment and Housing Act (California Government Code
section 12900); and regulations promulgated thereunder (Title 2, CCR, section 7285.0); Title 2, Division
3, Article 9.5 of the California Government Code commencing with section 11135; and Title 9, Division
4, Chapter 6 of the California Code of Regulations commencing with section 10800.
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B. EQUAL OPPORTUNITY – PROVIDER shall comply with California Government
Code, section 12990 and California Code of Regulations, Title II, Division 4, Chapter 5, in matters
related to the development, implementation, and maintenance of a nondiscrimination program.
PROVIDER shall not discriminate against any employee or applicant for employment because race,
religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition,
genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual
orientation, or military or veteran status. Such practices include retirement, recruitment, advertising,
hiring, layoff, termination, upgrading, demotion, transfer, rates of pay or other forms of compensation,
use of facilities, and other terms and conditions of employment. PROVIDER agrees to post in
conspicuous places, notices available to all employees and applicants for employment setting forth the
provisions of the Equal Opportunity Act (42 USC section 2000(e)) in conformance with Federal
Executive Order No. 11246. PROVIDER agrees to comply with the provisions of the Rehabilitation Act
of 1973 (29 USC Section 794).
C. SUSPENSION OF COMPENSATION – If an allegation of discrimination occurs,
DBH may withhold all further funds, until PROVIDER can show by clear and convincing evidence to the
satisfaction of DBH that funds provided under this Agreement were not used in connection with the
alleged discrimination.
D. NEPOTISM – Except by consent of the DBH Director or her designee, no person
shall be employed by PROVIDER who is related by blood or marriage to or who is a member of the
Board of Directors or an officer of PROVIDER.
E. NEW FACILITIES AND DISABILITY ACCESS – New facilities shall be
wheelchair accessible and provide access to the disabled, consistent with Title 9, California Code of
Regulations, section 10820. If a new facility will be utilized, a plan ensuring accessibility to the disabled
must be developed. DBH shall assess, monitor, and document PROVIDER’S compliance with the
Rehabilitation Act of 1973 and Americans with Disabilities Act of 1990 to ensure that
recipients/beneficiaries and intended recipients/beneficiaries of services are provided services without
regard to physical or mental disability and that PROVIDER has provided a facility accessible to the
physically disabled.
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33. ASSURANCES
In entering into this Agreement, PROVIDER certifies that it is not currently excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; that it
has not been convicted of a criminal offense related to the provision of health care items or services;
nor has it been reinstated to participation in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering into a
contract, that PROVIDER is ineligible on these grounds, COUNTY will remove PROVIDER from
responsibility for, or involvement with, COUNTY’s business operations related to the Federal Health
Care Programs and shall remove such PROVIDER from any position in which PROVIDER’s
compensation, or the items or services rendered, ordered or prescribed by PROVIDER 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 PROVIDER is reinstated into participation in the Federal Health Care
Programs. Further the PROVIDER agrees to the Disclosure of Criminal History and Civil Actions and
Certification regarding debarment suspension and other responsibility matters primary covered
transactions; PROVIDER must sign an appropriate Certification regarding debarment, suspension, and
other responsibility matters, attached hereto as Exhibit F, incorporated herein by reference and made
part of this Agreement.
A. If COUNTY has notice that PROVIDER has been charged with a criminal offense
related to any Federal Health Care Program, or is proposed for exclusion during the term on any
contract, PROVIDER 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 PROVIDER cease providing services until resolution of the charges or the
proposed exclusion.
B. PROVIDER agrees that all potential new employees of PROVIDER or
subcontractors of PROVIDER who, in each case, are expected to perform professional services under
this Agreement, will be queried as to whether (1) they are now or ever have been excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they have been
convicted of a criminal offense related to the provision of health care items or services; and or (3) they
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have been reinstated to participation in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility.
1) In the event the potential employee or subcontractor informs PROVIDER
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 PROVIDER hires or engages such
potential employee or subcontractor, PROVIDER 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), TERMINATION, of this Agreement, or require
adequate assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible
employee or subcontractor of PROVIDER 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. PROVIDER shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement (1) are not currently excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have not
been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
PROVIDER 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, PROVIDER will ensure that said employee or subcontractor does no work, either
direct or indirect, relating to services provided to COUNTY.
1) PROVIDER agrees to notify COUNTY immediately during the term of this
Agreement whenever PROVIDER learns that an employee or subcontractor who, in each case, is
providing professional services under this Agreement is excluded, suspended, debarred or otherwise
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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 the Section Three (3), TERMINATION, of this Agreement, or require
adequate assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible
employee or subcontractor of PROVIDER 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. PROVIDER 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 this Agreement.
E. PROVIDER agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of PROVIDER’s violation of the terms
of this Agreement.
34. AUDITS AND INSPECTIONS
The PROVIDER 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 PROVIDER shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all of such records and data necessary to ensure
PROVIDER’s compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00), PROVIDER
shall be subject to the examination and audit of the Auditor General for a period of three (3) years after
final payment under contract (Government Code Section 8546.7).
Notwithstanding the provisions stated in Section Two (2), TERM, of this Agreement, it is
acknowledged by the parties hereto that this Agreement shall continue in full force and effect until all
audit procedures and requirements as stated in this Agreement have been completed to the review and
satisfaction of COUNTY. PROVIDER shall bear all costs in connection with or resulting from any audit
and/or inspections including, but not limited to, actual costs incurred and the payment of any
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expenditures disallowed by either COUNTY, State, or Federal governmental entities, including any
assessed interest and penalties.
35. RECORDS
A. RECORD ESTABLISHMENT AND MAINTENANCE – PROVIDER shall establish
and maintain records in accordance with State and Federal rules and regulations in addition to those
requirements prescribed by COUNTY with respect to all matters covered by this Agreement. Except as
otherwise authorized by COUNTY, PROVIDER shall retain all other records for a period of five (5)
years after receiving the final payment under this Agreement or the earlier termination of this
Agreement, or until State and/or Federal audit findings applicable to such services are resolved,
whichever is later.
B. DOCUMENTATION – PROVIDER shall maintain adequate records in sufficient
detail to make possible an evaluation of services, and contain all the data necessary in reporting to the
State of California and/or Federal agency. All client records shall be maintained pursuant to applicable
State of California and Federal requirements concerning confidentiality.
C. REPORTS – PROVIDER shall submit to COUNTY monthly fiscal and all program
reports as further described in Section Sixteen (16) REPORTS – SUBSTANCE USE DISORDER
SERVICES. PROVIDER shall submit a complete and accurate year-end cost report for each fiscal year
affected by this Agreement, following the end of each fiscal year affected by this Agreement.
PROVIDER shall also furnish to COUNTY such statements, records, reports, data, and information as
COUNTY may request pertaining to matters covered by this Agreement. All reports submitted by
PROVIDER to COUNTY must be typewritten.
D. SUSPENSION OF COMPENSATION – In the event that PROVIDER fails to
provide reports specified in this Agreement, it shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance.
E. DISALLOWANCES – Payments by COUNTY shall be in arrears, for services
provided during the preceding month, within forty-five (45) days after receipt, verification and approval
of PROVIDER invoices by COUNTY’S DBH Contracts Division - SUD Services. If payment for services
are denied or disallowed by State; and subsequently resubmitted to COUNTY by PROVIDER, the
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disallowed portion will be withheld from the next reimbursement to the PROVIDER until COUNTY has
received has received reimbursement from State for said services.
F. CLIENT CONFIDENTIALITY – PROVIDER shall conform to and COUNTY shall
monitor compliance with all State and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements of 42 Code of Federal
Regulations § 2.1 et seq., Welfare and Institutions Code §§ 5328, 10850 and 14100.2, Health and
Safety Code §§ 11977 and 11812, Civil Code, Division 1, Part 2.6, and 22 California Code of
Regulations § 51009.
36. NOTICES
The persons and their addresses having authority to give and receive notices under this
Agreement include the following:
COUNTY PROVIDER
Director, Fresno County See Exhibit A
4441 East Kings Canyon
Fresno, CA 93702
Any and all notices between the COUNTY and the PROVIDER provided for or permitted
under this Agreement or by law shall be in writing and shall be deemed duly served when personally
delivered to one of the parties, or in lieu of such personal services, when deposited in the United States
Mail, postage prepaid, addressed to such party.
37. CHANGE OF LEADERSHIP/MANAGEMENT
Any and all notices between COUNTY and PROVIDER(S) provided for or permitted
under this Agreement or by law, shall be in writing and shall be deemed duly served when personally
delivered to one of the parties, or in lieu of such personal service, when deposited in the United States
Mail, postage prepaid, addressed to such party.
In the event of any change in the status of PROVIDER’s leadership or management,
PROVIDER shall provide written notice to COUNTY within thirty (30) days from the date of change.
Such notification shall include any new leader or manager’s name, address and qualifications.
“Leadership or management” shall include any employee, member, or owner of PROVIDER who either
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a) directs individuals providing services pursuant to this Agreement; b) exercises control over the
manner in which services are provided; or c) has authority over PROVIDER’s finances.
38. CHARITABLE CHOICE
PROVIDER may not discriminate in its program delivery against a client or potential
client on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal to
actively participate in a religious practice. Any specifically religious activity or service made available to
individuals by the PROVIDER must be voluntary as well as separate in time and location from County
funded activities and services. PROVIDER shall inform County as to whether it is faith-based. If
PROVIDER identifies as faith-based it must submit to DBH Contracts Division - SUD Services a copy of
its policy on referring individuals to alternate treatment PROVIDER, and include a copy of this policy in
its client admission forms. The policy must inform individuals that they may be referred to an
alternative provider if they object to the religious nature of the program, and include a notice to SUD
Services. Adherence to this policy will be monitored during annual site reviews, and a review of client
files. If PROVIDER identifies as faith-based, by July 1 of each year PROVIDER will be required to
report to SUD Services the number of individuals who requested referrals to alternate providers based
on religious objection.
39. LICENSING-CERTIFICATES
Throughout each term of this Agreement, PROVIDER and PROVIDER’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.
PROVIDER 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, PROVIDER and PROVIDER’s staff shall comply with all applicable
laws, rules or regulations, as may now exist or be hereafter changed.
40. AOD CERTIFICATION STANDARDS COMPLIANCE
The COUNTY requires all COUNTY contracted outpatient treatment providers of Alcohol
and Other Substance Use Disorder treatment services to comply with the California Department of
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Health Care Services (DHCS) Alcohol and Other Drug Program (AOD) Certification Standards. The
purpose of the AOD Certification Standards is to ensure an acceptable level of service quality is
provided to program participants.
COUNTY shall terminate this Agreement immediately in the event PROVIDER fails to
comply with the standards.
41. COMPLAINTS
PROVIDER shall log complaints and the disposition of all complaints from a consumer or
a consumer's family. PROVIDER shall provide a summary of the complaint log entries concerning
COUNTY-sponsored consumers to COUNTY at monthly intervals by the fifteenth (15th) day of the
following month, in a format that is mutually agreed upon. PROVIDER shall post signs informing
consumer of their right to file a complaint or grievance. PROVIDER shall notify COUNTY of all
incidents reportable to state licensing bodies that affect COUNTY consumers within twenty-four (24)
hours of receipt of a complaint.
Within fifteen (15) days after each incident or complaint affecting COUNTY-sponsored
consumers, PROVIDER shall provide COUNTY with information relevant to the complaint, investigative
details of the complaint, the complaint and PROVIDER's disposition of, or corrective action taken to
resolve the complaint.
42. DRUG FREE WORKPLACE
PROVIDER shall comply with the requirements of the Drug-Free Work Place Act of 1990
(California Government Code section 8350).
43. CHILD ABUSE REPORTING
PROVIDER shall utilize a procedure acceptable to the COUNTY to ensure that all of
PROVIDER’s employees, volunteers, consultants, subcontractors or agents performing services under
this Agreement shall report all known or suspected child abuse or neglect to one or more of the
agencies set forth in Penal Code section 11165.9. This procedure shall include having all of
PROVIDER’s employees, volunteers, consultants, subcontractors or agents performing services under
this Agreement sign a statement that he or she knows of and will comply with the reporting
requirements set forth in Penal Code section 11166. The statement to be utilized by PROVIDER for
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reporting is set forth in Exhibit G, “Notice of Child Abuse Reporting,” attached hereto and by this
reference incorporated herein.
44. TRAFFICKING IN PERSONS PROVISIONS
PROVIDER shall conform to all Federal statutes and regulations prohibiting trafficking in
persons, as well as trafficking-related activities, including, but not limited to the trafficking of persons
provisions in Section 106(g) of the Trafficking Victims Protection Act of 2000 (TVPA).
PROVIDER, PROVIDER’s employees, subrecipients, and subrecipients’ employees may
not:
A. Engage in severe forms of trafficking in persons during the period of time that the
award is in effect;
B. Procure a commercial sex act during the period of time that the award is in effect;
or
C. Use forced labor in the performance of the award or subawards under the award.
This agreement may be unilaterally terminated, without penalty, if PROVIDER or a
subrecipient that is a private entity is determined to have violated a prohibition of the TVPA or has an
employee who is determined by the DBH Director or her designee to have violated a prohibition of the
TVPA through conduct that is either associated with performance under the award or imputed to the
PROVIDER or their subrecipient using the standards and due process for imputing the conduct of an
individual to an organization that are provided in 2 C.F.R. Part 180, “OMB Guidelines to Agencies on
Government-wide Debarment and Suspension (Nonprocurement).
PROVIDER must inform the DBH Director or her designee immediately of any
information received from any source alleging a violation of a prohibition of the TVPA.
PROVIDER must sign a certification annually acknowledging the Trafficking Victims Protection Act of
2000 requirements (TVPA Certification), attached hereto as Exhibit H, incorporated herein by reference
and made part of this Agreement and must require all employees to complete annual TVPA training.
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45. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if PROVIDER 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 PROVIDER by completing Exhibit I “Disclosure of
Ownership and Control Interest Statement,” attached hereto and by this reference incorporated herein.
PROVIDER shall submit this form to the Department of Behavioral Health within thirty (30) days of the
effective date of this Agreement. Submissions shall be scanned pdf copies and are to be sent via email
to DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
A. Name and address of any person(s) whether it be an individual or corporation
with an ownership or controlling interest in the disclosing entity or managed care entity.
1) Address must include the primary business address, every business
location and P.O. Box address(es).
2) Date of birth and Social Security Number for individuals.
3) Tax identification number for other corporations or entities with ownership
or controlling interest in the disclosing entity.
B. Any subcontractor(s) in which the disclosing entity has five (5) percent or more
interest.
C. Whether the person(s) with an ownership or controlling interest of the disclosing
entity is related to another person having ownership or controlling interest as a parent, spouse, sibling
or child. Including whether the person(s) with ownership or controlling interest of the disclosing entity is
related to a person (parent, spouse, sibling or child) with ownership or has five (5) percent or more
interest in any of its subcontractors.
D. Name of any other disclosing entity in which an owner of the disclosing entity has
an ownership or control interest.
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E. The ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the date of the request;
and
F. Any significant business transactions between the provider and any wholly
owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the
date of the request.
G. Any person(s) with an ownership or control interest in the provider, or agent or
managing employee of the provider; and
1) Has been convicted of a criminal offense related to that person's
involvement in any program under Medicare, Medicaid, or the title XX services program since the
inception of those programs.
H. The ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the date of the request;
and
I. Any significant business transactions between the provider and any wholly
owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the
date of the request.
46. CONTROL REQUIREMENTS
Performance under this Agreement is subject to all applicable Federal and State laws,
regulations and standards. In accepting the State drug and alcohol combined program allocation
pursuant to California Health and Safety Code section 11757, PROVIDER shall establish written
accounting procedures consistent with applicable Federal and State laws, regulations and standards,
and shall be held accountable for audit exceptions taken by the State or COUNTY for failure to comply
with these requirements. These requirements include, but may not be limited to, those set forth in this
Agreement, and:
A. Division 10.5 of the California Health and Safety Code;
B. California Government Code sections 16366.1 through 16367.9 and 53130
through 53138;
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C. Title 9, Division 4 of the California Code of Regulations;
D. 42 United States Code (U.S.C.) section 300x-5;
E. 31 U.S.C. sections 7501-7507 (Single Audit Act of 1984; Single Audit Act
Amendments of 1996);
F. 2CFR Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit
Requirements for Federal Awards); and
G. Title 45, Part 96, Subparts B, C and L of the Code of Federal Regulations (Block
Grants).
47. PROPERTY OF THE COUNTY
A. All purchases over Five Thousand and No/100 Dollars ($5,000.00) shall be
identified as fixed assets and shall be maintained in COUNTY’s Asset Management System. Certain
purchases under Five Thousand and No/100 Dollars ($5,000.00) including but not limited to computers,
copiers, televisions, cameras and other sensitive items as determined by COUNTY’s DBH Director or
designee made during the life of this Agreement shall be identified as assets that can be inventoried
and maintained in COUNTY’s DBH Asset Inventory System. These 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 and shall by physically present when fixed and inventoried assets are returned to
COUNTY possession at the termination or expiration of this Agreement. PROVIDER is responsible for
returning to COUNTY all COUNTY owned 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.
PROVIDER 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, 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
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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.
B. The purchase of any equipment by PROVIDER 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 PROVIDERS services or activity under the terms of this
Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from equipment
purchased, which are incurred by PROVIDER, if prior written approval has not been obtained from
COUNTY.
C. The terms and conditions described in this Section are not applicable to the
leasing of vehicles by PROVIDER with the funds provided under this Agreement.
48. UNLAWFUL USE OF DRUGS AND ALCOHOL
PROVIDER shall ensure that information provided to clients contains a clearly written
statement that there shall be no unlawful use of drugs or alcohol associated with PROVIDER.
Additionally PROVIDER shall ensure that no aspect of the program includes any message in materials,
curricula, teachings, or promotion of the responsible use, if the use is unlawful, of drugs or alcohol
pursuant to Health and Safety Code (HSC) 11999-11999.3. PROVIDER shall maintain that any
unlawful use of drugs and alcohol is illegal and dangerous.
PROVIDER must sign the Unlawful Use of Drugs and Alcohol Certification, attached
hereto as Exhibit J, incorporated herein by reference and made part of this Agreement agreeing to
uphold the obligations of HSC 11999 – 11999.3.
COUNTY shall enforce the requirement of “No Unlawful Use” set forth by DHCS and
requires PROVIDER to enforce the requirement as well.
This agreement may be unilaterally terminated, without penalty, if PROVIDER or a
subcontractor that is a private entity is determined to have violated a prohibition of the Unlawful Use of
Drugs and Alcohol message or has an employee who is determined by the DBH Director or her
designee to have violated a prohibition of the Unlawful Use of Drugs and Alcohol message.
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49. RESTRICTION ON DISTRIBUTION OF STERILE NEEDLES
PROVIDER shall adhere to the State-County Contract requirement that no funds shall be used to carry
out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal
drug unless the DHCS chooses to implement a demonstration syringe services program for intravenous
drug users.
50. CONFIDENTIALITY OATH
PROVIDER shall ensure that all of its employees sign a written confidentiality oath,
attached hereto as Exhibit K, before they begin employment with PROVIDER and shall renew said
document annually thereafter. PROVIDER shall retain each employee’s written confidentiality oath for
COUNTY and DHCS inspection for a period of six (6) years following the termination of this agreement.
51. ADDITIONS/DELETIONS OF NEW PROVIDERS
COUNTY’s DBH Director, or her designee, reserves the right at any time during the term
of this Agreement to add new PROVIDER(S) to those listed in Exhibit A, “Youth Treatment Provider
List”. It is understood any such additions will not affect compensation paid to the other PROVIDER(S),
and therefore such additions may be made by COUNTY without notice to or approval from other
PROVIDER(S) under this agreement. These same provisions shall apply to the deletion of any
PROVIDER listed in Exhibit A, “Youth Treatment Provider List,’ except that deletions shall be made by
written mutual agreement between the COUNTY and the particular PROVIDER to be deleted, or shall
be in accordance with the provisions of Section Three (3) TERNINATION of this Agreement.
52. SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create
a joint venture among PROVIDER(S). By execution of this Agreement, PROVIDER(S) understands
that a separate Agreement is formed between each individual PROVIDER and COUNTY.
53. GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
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54. ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire Agreement between
PROVIDER and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
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EXECUTED AND EFF ECTI V E as of t he d ate fi rst abov e set forth .
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PROVI DER(S)
SEE REVISED EXHIBIT A-1
17 FOR ACCOU NTI NG USE O NLY:
18 ORG No .: 56302081
Accou nt No .: 7295
19 Requ isit ion No.: 5631810021
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COUNTY OF FRESNO
a irperson of the B oa rd
t he Count y of F resno
ATTEST:
Be rn ice E . Seidel
C lerk of t he Board of Supervisors
County of Fresn o , St at e of Ca l iforn i a
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(Authorized · nature)
Leon ±f-ocll e r:1 C-E 0Print Name & Title , t Jro 1J. f l1r\rAVl u'cL{ 1)--; i1e •1 S'utit 110 35u no , CA . qo 17D Mailing Address
FOR ACCOUNTING USE ONLY:
ORG No.: 56302081
Account No.: 7295
Requisition No.: 5631810021
42
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James C. Callaghan Jr.
Print Name & Title
9465 Farnham Street
San Diego, CA 92123
Mailing Address
FOR ACCOUNTING USE ONLY:
ORG No.: 56302081
Account No.: 7295
Requisition No.: 5631810021
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Pya,lnc. .
/Authorize�
Print Na e & Title
� l S""l. f\J, if.\:\\ 'bt0t.K -tl D
Mailing Address
FOR ACCOUNTING USE ONLY:
ORG No.: 56302081
Account No.: 7295
Requisition No.: 5631810021
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3
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(Autho ized Signature)
� �v\ I.A )&�(Ulf-t C ti:. o Print Name & Title ' 5 -".) 11-c JJ M o...v ll--S A:v L-<; u.. 1 h-I J o6
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fusVlt\1 cft �>,)/ Mailing Address
FOR ACCOUNTING USE ONLY:
ORG No.: 56302081
Account No.: 7295
Requisition No.: 5631810021
45
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4 Sl..o.w"-' A. � .. 1<;
Print Name & Title
, S «Nior V;u -r'r«si.Jel\tc •
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'f re!; "'b I Co.l;+-'c,,-si (t 't g r,:1,. 7
Mailing Address
FOR ACCOUNTING USE ONLY:
ORG No.: 56302081
Account No.: 7295
Requisition No.: 5631810021
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Exhibit A
Page 1 of 1
Note: Current service locations for these providers are available in the provider directory on the
county’s SUD website (http://www.co.fresno.ca.us/departments/behavioral-health/substance-use-
disorder-services/looking-for-help).
Youth Treatment Services Provider List
Provider Annual Contract Maximum
Kings View Corporation
Remit to:
1410 F St., Suite 101
Fresno, CA 93706
(559) 875-6300
$25,000.00
Mental Health Systems, Inc.
Remit to:
9465 Farnham St.
San Diego, CA 92123
(858) 573-2600
$15,000.00
Panacea, Inc.
Remit to:
3152 N. Millbrook Ave., Suite D
Fresno, CA 93703
(559) 241-0364
$25,000.00
Promesa Behavioral Health, Inc.
Remit to:
7120 N. Marks Ave., Suite 110
Fresno, CA 93711
(559) 439-5437
$10,000.00
WestCare California, Inc.
Remit to:
PO Box 12107
Fresno, CA 93776
(559) 255-8838
$25,000.00
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
1
rev 2017 Dec
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
•Deliver quality care
•Maximize resources while focusing on efficiency
•Provide an excellent care experience
•Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit B
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2
rev 2017 Dec
2.Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3.Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4.Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5.Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit B
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
3
rev 2017 Dec
6.Principle Six - Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7.Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8.Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9.Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit B
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
4
rev 2017 Dec
10.Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11.Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit B
Exhibit C
Department of Health Care Services
Substance Use Disorders - Program, Prevention and Fiscal Division
Drug Medi-Cal (DMC) Rates for Fiscal Year 2017-18
Non-Perinatal DMC
Description Unit of Service (UOS) FY 2017-18
UOS Rate**
Narcotic Treatment Program (NTP) - Methadone Daily $13.11
NTP - Individual Counseling One 10-minute Increment $15.37
NTP - Group Counseling One 10-minute Increment $3.43
Intensive Outpatient Treatment Face-to-Face Visit $58.53
Naltrexone (*) Face-to-Face Visit $19.06
Outpatient Drug Free (ODF) Individual Counseling Face-to-Face Visit (Per Person) $76.91
ODF Group Counseling Face-to-Face Visit (Per Person) $30.89
Perinatal DMC
Description Unit of Service (UOS) FY 2017-18
UOS Rate**
NTP - Methadone Daily $14.11
NTP - Individual Counseling One 10-minute Increment $16.39
NTP - Group Counseling One 10-minute Increment $4.28
Intensive Outpatient Treatment Face-to-Face Visit $84.43
Perinatal Residential Daily $90.14
ODF Individual Counseling Face-to-Face Visit (Per Person) $81.93
ODF Group Counseling Face-to-Face Visit (Per Person) $38.56
*From FY 2002-03 through FY 2008-09, Naltrexone was frozen at the $21.19 (FY 1999-2000) approved rate. Counties
and service providers have not provided, submitted claims, nor reported cost for this service since FY 1997-98. For FY
2009-10, the $21.19 frozen rate was reduced by 10 percent to $19.07. Excluding county administration from the cost
data used to produce the $21.19 frozen approved rate decreased it to $19.06. Drug Medi-Cal used $19.06 as the FY
2017-18 developed rate.
** FY 2009-2010 rates were adjusted by the cumulative growth of the change in the Implicit Price Deflator (IDP), in
accordance with Welfare & Institutions Code Section 14021.9(b). The 15.6 percent is a year-to-year summation of the
change in IDP's which are as follows: 0% for FY 2009-10, 3.2% for FY 2010-11, 2.5% for FY 2011-12, 1.9% for
FY 2012-13, 2.1% for FY 2013-14, 1.2% for FY 2014-15, 0.4% for FY 2015-16, 1.9% for FY 2016-17, and 2.4% for
FY 2017-18.
Exhibit D
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit D
Page 2 of 2
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3)Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5)Authorized Signature
Signature: Date:
Exhibit E
Page 1 of 2
CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES
CONTRACTOR shall adhere to and develop written procedures in accordance with the below standards
adapted from the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in
Health Care:
Culturally Competent Care:
1.Organizations must ensure that consumers receive from all staff members effective,
understandable, and respectful care that is provided in a manner compatible with
their cultural health beliefs and practices and preferred language.
2.Organizations must implement strategies to recruit, retain, and promote at all levels
of the organization a diverse staff and leadership that are representative of the
demographic characteristics of the service area.
3.Organizations must ensure that staff at all levels and across all disciplines receive
ongoing education and training in culturally and linguistically appropriate service
delivery.
Language Access Services:
4.Organizations must offer and provide language assistance services, including bilingual
staff and interpreter services, at no cost to consumers with limited English proficiency
at all points of contact, in a timely manner during all hours of operation.
5.Organizations must provide to consumers in their preferred language both verbal
offers and written notices informing them of their right to receive language assistance
services.
6.Organizations must assure the competence of language assistance provided to limited
English proficient consumers by interpreters and bilingual staff. Family and friends
should not be used to provide interpretation services (except on the request of the
consumer).
7.Organizations must make available easily understood patient-related materials and
post signage in the languages of the commonly encountered groups and/or groups
represented in the service area.
Organizational Supports:
8.Organizations must develop, implement, and promote a written strategic plan that
outlines clear goals, policies, operational plans, and management
accountability/oversight mechanisms to provide culturally and linguistically
appropriate services.
Exhibit E
Page 2 of 2
9. Organizations must conduct initial and ongoing organizational self-assessments of
CLAS related activities and are encouraged to integrate cultural and linguistic
competence-related measures into their internal audits, performance improvement
programs, consumer satisfaction Assessments, and Outcomes-Based Evaluations.
10. Organizations must ensure that data on the individual consumer’s race, ethnicity, and
spoken and written language are collected in program records, integrated into the
organizations management information systems, and periodically updated.
11. Organizations must maintain a current demographic, cultural, and epidemiological
profile of the community as well as a needs assessment to accurately plan for and
implement services that respond to the cultural and linguistic characteristics of the
service area.
12. Organizations must develop participatory, collaborative partnerships with
communities and utilize a variety of formal and informal mechanisms to facilitate
community and consumer involvement in designing and implementing CLAS-related
activities.
13. Organizations must ensure that conflict and grievance resolution processes are
culturally and linguistically sensitive and capable of identifying, preventing, and
resolving cross-cultural conflicts or complaints by consumers.
14. Organizations must regularly make available to the public information about their
progress and successful innovations in implementing these standards and to provide
public notice in their communities about the availability of this information.
15. Organizations must ensure communication regarding the organization’s progress in
implementing and sustaining CLAS to all stakeholders, constituents, and general
public.
CONTRACTOR shall develop written procedures in accordance with the above standards. The
provisions of this Agreement are not intended to abrogate any provisions of law or regulation existing
or enacted during the term of this Agreement.
Exhibit F
Page 1 of 3
C:\USERS\MPRICHARD\DESKTOP\YTS CONTRACT AND SOW\EXHIBITS\EXHIBIT F DISCLOSURE STATEMENT.DOC
DISCLOSURE – CRIMINAL HISTORY & CIVIL ACTIONS:
In their proposal, the bidder is required to disclose if any of the following conditions apply to
them, their owners, officers, corporate managers and partners (hereinafter collectively
referred to as “Bidder”):
• Within the three-year period preceding the proposal, they have been convicted of, or
had a civil judgment rendered against them for:
o fraud or a criminal offense in connection with obtaining, attempting to obtain, or
performing a public (federal, state, or local) transaction or contract under a
public transaction;
o violation of a federal or state antitrust statute;
o embezzlement, theft, forgery, bribery, falsification, or destruction of records; or
o false statements or receipt of stolen property
• Within a three-year period preceding their proposal, they have had a public transaction
(federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate a Bidder from
consideration. The information will be considered as part of the determination of whether to
award the contract and any additional information or explanation that a Bidder elects to submit
with the disclosed information will be considered. If it is later determined that the Bidder failed
to disclose required information, any contract awarded to such Bidder may be immediately
voided and terminated for material failure to comply with the terms and conditions of the
award.
Any Bidder who is awarded a contract must sign an appropriate Certification Regarding
Debarment, Suspension, and Other Responsibility Matters, pages 2 and 3 of this Exhibit,
Additionally, the Bidder awarded the contract must immediately advise the County in writing if,
during the term of the agreement: (1) Bidder becomes suspended, debarred, excluded or
ineligible for participation in federal or state funded programs or from receiving federal funds
as listed in the excluded parties list system (http://www/epls/gov); or (2) any of the above
listed conditions become applicable to Bidder. The Bidder will indemnify, defend and hold the
County harmless for any loss or damage resulting from a conviction, debarment, exclusion,
ineligibility or other matter listed in the signed Certification Regarding Debarment,
Suspension, and Other Responsibility Matters.
Exhibit F
Page 2 of 3
C:\USERS\MPRICHARD\DESKTOP\YTS CONTRACT AND SOW\EXHIBITS\EXHIBIT F DISCLOSURE STATEMENT.DOC
CERTIFICATION REGARDING DEBARMENT,
SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED
TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
2. The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant shall
submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this
clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which
this proposal is being submitted for assistance in obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
Exhibit F
Page 3 of 3
C:\USERS\MPRICHARD\DESKTOP\YTS CONTRACT AND SOW\EXHIBITS\EXHIBIT F DISCLOSURE STATEMENT.DOC
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it,
its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State
or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or Company)
Exhibit G
Page 1 of 1
NOTICE OF CHILD ABUSE REPORTING LAW
The undersigned hereby acknowledges that Penal Code section 11166 and the
contractual obligations between County of Fresno (COUNTY) and PROVIDER(S)
related to provision of alcohol and drug abuse treatment services for Fresno County
residents, require that the undersigned report all known or suspected child abuse or
neglect to one or more of the agencies set forth in Penal Code (P.C.) section (§) 11165.9.
For purposes of the undersigned’s child abuse reporting requirements, “child
abuse or neglect” includes physical injury inflicted by other than accidental means upon a
child by another person, sexual abuse as defined in P.C. §11165.1, neglect as defined in
P.C. §11165.2, willful cruelty or unjustifiable punishment as defined in P.C. §11165.3,
and unlawful corporal punishment or injury as defined in P.C. §11165.4.
A child abuse report shall be made whenever the undersigned, in his or her
professional capacity or within the scope of his or her employment, has knowledge of or
observes a child whom the undersigned knows or reasonably suspects has been the victim
of child abuse or neglect. (P.C §11166.) The child abuse report shall be made to any
police department or sheriff’s department (not including a school district police or
security department), or to any county welfare department, including Fresno County
Department of Children and Family Services’ 24 Hour CARELINE. (See PC §11165.9.)
For purposes of child abuse reporting, a “reasonable suspicion” means that it is
objectively reasonable for a person to entertain a suspicion, based upon facts that could
cause a reasonable person in a like position, drawing, when appropriate, on his or her
training and experience, to suspect child abuse or neglect. The pregnancy of a child does
not, in and of itself, constitute a basis for reasonable suspicion of sexual abuse. (P.C.
§11166(a)(1).)
Substantial penalties may be imposed for failure to comply with these child abuse
reporting requirements.
Further information and a copy of the law may be obtained from the department
head or designee.
I have read and understand the above statement and agree to comply with the
child abuse reporting requirements.
__________________________________ ________________________
SIGNATURE DATE
0980fadx
Exhibit H
Page 1 of 1
TRAFFICKING VICTIMS PROTECTION ACT OF 2000
CERTIFICATION
I, ______________________________________, as an authorized agent of (Print Name)
________________________________________, acknowledge the requirement to (Organization Name)
comply with the Trafficking Victims Protection Act of 2000 (TVPA), specifically Section
106(g), which authorizes the County of Fresno to terminate a contract, without penalty,
if this organization or its employees, or a subcontractor or its employees:
• Engages in severe forms of trafficking in persons during the period of time that
the award is in effect;
• Procures a commercial sex act during the period of time that the award in in
effect; or
• Uses forced labor in the performance of the award or subawards under the
award.
I understand that the TVPA establishes human trafficking and related offenses
as federal crimes and attaches severe penalties to them. I will immediately inform the
County of Fresno, Department of Behavioral Health, Contracts Division – Substance
Use Disorder (SUD) Services immediately of any information received from any
source alleging a violation of the TVPA by either this organization or its employees, or
a subcontractor or its employees during the term of this contract.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of the TVPA and, if found in violation, will be immediately
terminated. I agree to submit this signed certification annually on behalf of the
organization acknowledging requirements under the TVPA and attesting that all
employees will receive annual TVPA training, and that documentation of training will
be placed in personnel files.
Signature:_____________________________ Date:______________________
Title:_________________________________
Exhibit I
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 I
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
Attachment J
Page 1 of 1
UNLAWFUL USE OF DRUGS AND ALCOHOL
CERTIFICATION
I, ______________________________________, as an authorized agent of
(Print Name)
________________________________________, acknowledge the requirement to
(Organization Name)
comply with California HSC 11999-11999.3, which authorizes the County of Fresno to
terminate a contract, without penalty, if this organization or its employees, or a
subcontractor or its employees fail to ensure that:
• The program contains a component that clearly explains in written materials
that there shall be no unlawful use of drugs or alcohol. No aspect of a drug- or
alcohol-related program shall include any message on the responsible use, if
the use is unlawful, of drugs or alcohol;
• All aspects of a drug- or alcohol-related program are consistent with the “no
unlawful use” message, including, but not limited to, program standards,
curricula, materials, and teachings; and
• The “no unlawful use” of drugs and alcohol message contained in drug- or
alcohol-related programs applies to the use of drugs and alcohol prohibited by
law.
I understand that the State of California enforces an Unlawful Use policy in
which there is zero tolerance for promoting the unlawful use of and drugs or alcohol in
an AOD treatment facility. If this organization fails to satisfy the guidelines adopted by
the State of California, the drug or alcohol program shall not receive state funds and
their contract with Fresno County will be terminated.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of HSC 11999-11999.3 and, if found in violation, will be
immediately terminated.
Signature:_____________________________ Date:______________________
Title:_________________________________
3133 N Millbrook, Fresno, California 93703
FAX (559) 600-7673 www.co.fresno.ca.us
The County of Fresno is an Equal Employment Opportunity Employer
County of Fresno
DEPARTMENT OF BEHAVIORAL HEALTH
DAWAN UTECHT
DIRECTOR
Exhibit K
Page 1 of 1
PRIVACY AND SECURITY AGREEMENT REGARDING AUTHORIZED ACCESS TO
CONFIDENTIAL PROTECTED HEALTH INFORMATION FOR FRESNO COUNTY DEPARTMENT
OF BEHAVIORAL HEALTH (DBH) EMPLOYEES AND/OR NON-DBH SUD SERVICES
WORKFORCE MEMBERS
OATH OF CONFIDENTIALITY
As a condition of obtaining access to any Protected Health Information (PHI) that is necessary to carry
out my function with DBH, I ___________________________, agree to not divulge any PHI to
unauthorized persons. Furthermore, I maintain that I will not publish or otherwise make public any
information regarding persons who receive Substance Use Disorder Services such that the persons who
receive or have received such services are identifiable.
Access to such data shall be limited to Fresno County DBH personnel, subcontractors, and
subcontractors’ personnel who require this information in the performance of their duties and have signed
an Oath of Confidentiality with DBH.
By signing this oath, I agree to uphold the security and confidentiality requirements outlined by the Medi-
Cal Privacy and Security Agreement signed by DBH, surveillance and safeguarding announcements
issued by DHCS, and other applicable terms and stipulations provided by the HIPAA doctrine as well as
other relevant state and federal regulations.
I hereby certify my understanding of the need to:
1. Exercise due care to preserve data integrity and confidentiality.
2. Treat passwords and user accounts as confidential information.
3. Take reasonable precautions to ensure the protection of PHI from unauthorized access.
4. Notify DHCS when there is a possible security violation including unauthorized access to PHI by
completing a “Privacy Incident Report” at:
http://www.dhcs.ca.gov/formsandpubs/laws/priv/Pages/DHCSBusinessAssociatesOnly.aspx and
return the completed form to: privacyofficer@dhcs.ca.gov.
I recognize that unauthorized release of confidential information may make me subject to civil and
criminal sanctions pursuant to the provisions of the Welfare and Institutions Code Section 14100.2,
Welfare and Institutions Code Section 5328 et seq. and the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). I further acknowledge that the unauthorized release of confidential
information as described in this document may result in disciplinary action up to and including
termination of any office of employment or contract.
Agency Name:
Signature:
____________________________________
Date:
____________________________________