HomeMy WebLinkAboutAgreement A-18-687 with Comprehensive Youth Services of Fresno.pdf1
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Agreement No . 18-687
AGREEMENT
THIS AGREEMENT is made and entered into this _1_1=th~ __ day of December , 2018 , by
and between the COUNTY OF FRESNO, a Political Subdivision of the State of California , hereinafter
referred to as "COUNTY", and COMPREHENSIVE YOUTH SERVICES OF FRESNO, INC., a California
non-profit Corporation , whose business address is 4545 N West Avenue, Fresno , CA 93705 , hereinafter
referred to as "CONTRACTOR" (collectively the "parties").
W I T N E S S E T H:
WHEREAS , COUNTY, through its Department of Behavioral Health (DBH), is in need of a qual ified
agency, to operate a Mental Health Services Act (MHSA) funded Functional Family Therapy (FFT)
Program to deliver Prevention and Early Intervention (PEI) mental health and community services to
underserved or unserved high risk youth ages 11-18 with Serious Emotional Disturbance (SEO) who
although not incarcerated , are involved with the juvenile justice system ; and
WHEREAS , COUNTY, through its Department of Behavioral Health (DBH), is a Mental Health Plan
(MHP) as defined in Title 9 of the California Code of Regulations (C.C .R.), section 1810.226 ; and
WHEREAS , CONTRACTOR is qualified and willing to operate said FFT services pu rsuant to the
16 terms and conditions of this Agreement.
17 NOW, THEREFORE , in consideration of their mutual covenants and conditions , the parties hereto
18 agree as follows:
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1. SERVICES
A . CONTRACTOR shall perform all services and fulfill all respons ibilities as set forth in
Exhibit A "Summary of Services", attached hereto and by this reference incorporated herein and made part
of this Agreement.
B . CONTRACTOR shall also perform all services and fulfill all responsib ilities as
specified in COUNTY's Request for Proposal (RFP) No. 18-036 dated March 19 , 2018, Addendum No.
One (1) to COUNTY's RFP No. 18-036 dated March 21 , 2018 , and Addendum No. Two (2) to COUNTY's
RFP No. 18-036 dated April 17, 2018 , Addendum No. Three (3) to COUNTY's RFP No. 18-036 dated April
17, 2018 , collectively referred to herein as COUNTY's Revised RFP , and CONTRACTOR's response to
sa id Revised RFP dated April 30 , 2018 all incorporated herein by reference and made part of this
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Agreement. 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 all Exhibits
and excluding the Revised RFP and Contractor’s Response to Revised RFP; 2) to the Revised RFP; and
3) to CONTRACTOR’s Response to the Revised RFP. A copy of COUNTY’s Revised RFP No. 18-036
and CONTRACTOR’s response thereto shall be retained and made available during the term of this
Agreement by COUNTY’s DBH Contracts Division.
C. CONTRACTOR shall perform all services defined in Exhibit A in accordance with
Exhibit C “Guiding Principles of Care Delivery”, attached hereto and by this reference incorporated herein
and made part of this Agreement.
D. It is acknowledged by all parties hereto that COUNTY's DBH shall monitor the
services provided by CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement.
E. CONTRACTOR shall participate in periodic workgroup meetings consisting of staff
from COUNTY's DBH to discuss service requirements, data reporting, outcomes measurement, training,
policies and procedures, overall program operations, and any problems or foreseeable problems that may
arise.
F. Changes to any CONTRACTOR corporate information or service sites shall be
made upon 30 days advance written notification to COUNTY’s DBH Director and upon written approval
from COUNTY’s DBH Director or designee.
G. CONTRACTOR shall maintain requirements as a COUNTY MHP organizational
provider throughout the term of this Agreement. If, for any reason, this status is not maintained, COUNTY
may terminate this Agreement pursuant to Section 3 of this Agreement.
H. CONTRACTOR agrees that, prior to providing services under the terms and
conditions of this Agreement, it shall have appropriate staff hired and in place for program services and
operations, or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate this
Agreement as to Section Three (3) of this Agreement.
2. TERM
This Agreement shall become effective on the 1st day of January, 2019 and shall terminate
on the 30th day of June, 2021.
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This Agreement may be extended for two (2) additional twelve (12) month periods upon the
written approval of both parties not later than sixty (60) days prior to the first day of the next twelve (12)
month extension period. The COUNTY’s DBH Director or designee is authorized to execute such written
approval on behalf of COUNTY based on CONTRACTOR’s satisfactory performance.
3. TERMINATION
A. Non-Allocation of Funds – The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
B. Breach of Contract – COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4) Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by the COUNTY of any
breach of this Agreement or any default which may then exist on the part of the CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to the COUNTY with respect to the breach or
default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment to the
COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of the
COUNTY were not expended in accordance with the terms of this Agreement. CONTRACTOR shall
promptly refund any such funds upon demand or, at COUNTY’s option, such repayment shall be deducted
from future payments owing to CONTRACTOR under this Agreement.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by CONTRACTOR or COUNTY, upon the giving of sixty (60) days advance
written notice of an intention to terminate. COUNTY’s DBH Director, or designee, shall have the authority
to issue such notice of an intention to terminate on behalf of COUNTY.
D. CONTRACTOR may terminate this Agreement. If terminated by CONTRACTOR,
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termination shall require sixty (60) days advance written notice of intent to terminate (with allowance for
appropriate clinical transition of clients prior to termination of services), transmitted by CONTRACTOR to
COUNTY by Certified or Registered U.S. Mail, Return Receipt Requested, addressed to the office of
COUNTY as follows:
Director (or designee) Department of Behavioral Health 3133 N. Millbrook Fresno, CA 93703
4. COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with the budget set forth in Exhibit B “Budget”, attached hereto and by this
reference incorporated herein and made part of this Agreement.
A. Maximum Contract Amount
The maximum amount payable to CONTRACTOR for the period of January 1, 2019
through June 30, 2019 shall not exceed One Million Fifty Thousand Nine Hundred Eighty Three
($1,051,983.00). It is understood by CONTRACTOR and COUNTY that the total of Mental Health
Services Act (MHSA) Prevention and Early Intervention (PEI) funds payable under this Agreement to
CONTRACTOR shall not exceed Three Hundred Thirty Six Thousand Five Hundred Three and No/100
Dollars ($336,503.00). It is also understood by CONTRACTOR and COUNTY that CONTRACTOR is
estimated to generate a total of Seven Hundred Fifteen Thousand Four Hundred Eighty and No/100
Dollars ($715,480.00) in Medi-Cal under this Agreement to offset CONTRACTOR program costs as set
forth in Exhibit B.
The maximum amount payable to CONTRACTOR for the period of July 1, 2019
through June 30, 2020 shall not exceed Two Million Ninety Six Thousand Two Hundred and No/100
Dollars ($2,096,200.00). It is understood by CONTRACTOR and COUNTY that the total of MHSA PEI
funds payable under this Agreement to CONTRACTOR shall not exceed Six Hundred Seventy Three
Thousand and Five and No/100 Dollars ($673,005.00). It is also understood by CONTRACTOR and
COUNTY that CONTRACTOR is estimated to generate a total of One Million Four Hundred Twenty Three
Thousand One Hundred Ninety Five and No/100 Dollars ($1,423,195.00) in Medi-Cal under this
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Agreement to offset CONTRACTOR program costs as set forth in Exhibit B.
The maximum amount payable to CONTRACTOR for the period of July 1, 2020
through June 30, 2021 shall not exceed Two Million One Hundred Thirty One Thousand Three Hundred
Seventy Three and No/100 Dollars ($2,131,373.00). It is understood by CONTRACTOR and COUNTY
that the total of MHSA PEI funds payable under this Agreement to CONTRACTOR shall not exceed Six
Hundred Seventy Three Thousand Five and No/100 Dollars ($673,005.00). It is also understood by
CONTRACTOR and COUNTY that CONTRACTOR is estimated to generate a total of One Million Four
Hundred Fifty Eight Thousand Three Hundred Sixty Eight and No/100 Dollars ($1,458,368.00) in Medi-Cal
under this Agreement to offset CONTRACTOR program costs as set forth in Exhibit B.
If this Agreement is extended pursuant to Paragraph 2, the maximum amount
payable to CONTRACTOR for the period of July 1, 2021 through June 30, 2022 shall not exceed Two
Million One Hundred Eight Six Thousand Two Hundred Nineteen and No/100 Dollars ($2,186,219.00). It is
understood by CONTRACTOR and COUNTY that the total of MHSA PEI funds payable under this
Agreement to CONTRACTOR shall not exceed Six Hundred Seventy Three Thousand Five and No/100
Dollars ($673,005.00). It is also understood by CONTRACTOR and COUNTY that CONTRACTOR is
estimated to generate a total of One Million Five Hundred Thirteen Thousand Two Hundred Fourteen and
No/100 Dollars ($1,513,214.00) in Medi-Cal under this Agreement to offset CONTRACTOR program costs
as set forth in Exhibit B.
If this Agreement is extended pursuant to Paragraph 2, the maximum amount
payable to CONTRACTOR for the period of July 1, 2022 through June 30, 2023 shall not exceed Two
Million Two Hundred Thirty Two Thousand One Hundred Sixty Eight and No/100 Dollars ($2,232,168.00).
It is understood by CONTRACTOR and COUNTY that the total of MHSA PEI funds payable under this
Agreement to CONTRACTOR shall not exceed Six Hundred Seventy Three Thousand Five and No/100
Dollars ($673,005.00). It is also understood by CONTRACTOR and COUNTY that CONTRACTOR is
estimated to generate a total of One Million Five Hundred Fifty Nine Thousand One Hundred Sixty Three
and No/100 Dollars ($1,559,163.00) in Medi-Cal under this Agreement to offset CONTRACTOR program
costs as set forth in Exhibit B.
In no event shall the maximum contract amount, for the full contract term of January
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1, 2019 through June 30, 2023 (if extended for the two (2) additional years pursuant to Paragraph 2), for all
the services provided by CONTRACTOR to COUNTY under the terms and conditions of this Agreement
be in excess of Nine Million Six Hundred Ninety Seven Thousand Nine Hundred Forty Three and No/100
Dollars ($9,697,943.00) during the total term of this Agreement.
Payment shall be made upon certification or other proof satisfactory to COUNTY’s
DBH that services have actually been performed by CONTRACTOR as specified in this Agreement.
B. If CONTRACTOR fails to generate the Medi-Cal revenue and/or client fee
reimbursement amounts set forth in Exhibit B, COUNTY shall not be obligated to pay the difference
between these estimated amounts and the actual amounts generated.
It is further understood by COUNTY and CONTRACTOR that any Medi-Cal
revenue and/or client fee reimbursements above the amounts stated herein will be used to directly offset
the COUNTY’s contribution of COUNTY funds identified in Exhibit B. The offset of funds will also be
clearly identified in monthly invoices received from CONTRACTOR as further described in Section Five (5)
of this Agreement.
Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the Federal Internal
Revenue Services (IRS) published rate.
C. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply with
any provision of this Agreement, COUNTY shall be relieved of its obligation for further compensation.
D. Payments shall be made by COUNTY to CONTRACTOR in arrears for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval by
COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made after
receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as
identified in Exhibit B, in the performance of this Agreement and shall be documented to COUNTY on a
monthly basis by the tenth (10th) of the month following the month of said expenditures. The parties
acknowledge that CONTRACTOR will be performing hiring, training, and credentialing of staff, and
COUNTY will be performing additional staff credentialing to ensure compliance with State and Federal
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regulations.
E. COUNTY shall not be obligated to make any payments under this Agreement if the
request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
All final invoices shall be submitted by CONTRACTOR within sixty (60) days
following the final month of service for which payment is claimed. No action shall be taken by COUNTY on
invoices submitted beyond the sixty (60) day closeout period. Any compensation which is not expended
by CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
COUNTY.
F. The services provided by CONTRACTOR under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by the
State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred payment
shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The period of
time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s delay of
payment to COUNTY plus forty-five (45) days.
G. CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR deficiency discovered through the State audit
process and COUNTY utilization review during the course of this Agreement. At COUNTY’s election, the
disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or shall be
withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive reimbursement
for any units of services rendered that are disallowed or denied by the Fresno County Mental Health Plan
(Mental Health Plan) utilization review process or through the State Department of Health Care Services
(DHCS) cost report audit settlement process for Medi-Cal eligible clients. Notwithstanding the above,
COUNTY must notify CONTRACTOR prior to any State audit process and/or COUNTY utilization review.
To the extent allowable by law, CONTRACTOR shall have the right to be present during each phase of
any State audit process and/or COUNTY utilization review and shall be provided all documentation related
to each phase of any State audit process and/or COUNTY utilization review. Additionally, prior to any
disallowances/audit exceptions becoming final, CONTRACTOR shall be given at least 10 business days to
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respond to such proposed disallowances/audit exceptions.
H. It is understood by CONTRACTOR and COUNTY that this Agreement is funded
with mental health funds to serve children/youth with Seriously Emotionally Disturbed (SED) disorders,
many of whom have co-occurring substance use disorders. It is further understood by CONTRACTOR
and COUNTY that funds shall be used to support appropriately integrated and documented treatment
services for co-occurring mental health and substance use disorders.
5. INVOICING
A. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each
month for the prior month’s actual services rendered to DBH–Invoices@fresnocounty.ca.gov. After
CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for payment,
certify the expenditure, and submit electronic claiming data into COUNTY’s electronic information system
for all clients, including those eligible for Medi-Cal as well as those that are not eligible for Medi-Cal,
including contracted cost per unit and actual cost per unit. COUNTY must pay CONTRACTOR before
submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible clients.
B. At the discretion of COUNTY’s DBH Director or designee, if an invoice is incorrect
or is otherwise not in proper form or substance, COUNTY’s DBH Director or designee, shall have the right
to withhold payment as to only that portion of the invoice that is incorrect or improper after five (5) days
prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a period of
ninety (90) days after notification of an incorrect or improper invoice. If after the ninety (90) day period, the
invoice(s) is still not corrected to COUNTY DBH’s satisfaction, COUNTY’s DBH Director or designee, may
elect to terminate this Agreement, pursuant to the termination provisions stated in Section Three (3) of this
Agreement. In addition, for invoices received ninety (90) days after the expiration of each term of this
Agreement or termination of this Agreement, at the discretion of COUNTY’s DBH Director or designee,
COUNTY’s DBH shall have the right to deny payment of any additional invoices received.
C. Monthly invoices shall include a client roster, identifying volume reported by
guarantor group clients served (including third party payer of services) by month and year-to-date,
including percentages.
D. CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a
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detailed general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL reports
and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until
there is compliance, as further described in Section Five (5) herein.
E. CONTRACTOR will remit annually within ninety (90) days from June 30, a schedule
to provide the required information on published charges for all authorized direct specialty mental health
services. The published charge listing will serve as a source document to determine the CONTRACTOR’s
usual and customary charge prevalent in the public mental health sector that is used to bill the general
public, insurers or other non-Medi-Cal third party payers during the course of business operations.
F. CONTRACTOR shall submit monthly staffing reports that identify all direct service
and support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking
tool to determine if CONTRACTOR’s program is staffed according to the services provided under this
Agreement.
G. CONTRACTOR must maintain financial records for a period of ten (10) years or
until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for
any disallowances related to inadequate documentation.
H. CONTRACTOR is responsible for collecting and managing of data in a manner to
be determined by DHCS and COUNTY’s Mental Health Plan in accordance with applicable rules and
regulations. COUNTY’s electronic information system is a critical source of information for purposes of
monitoring service volume and obtaining reimbursement.
I. CONTRACTOR shall submit service data into COUNTY’s electronic information
system, in accordance with COUNTY’s DBH documentation standards, to allow COUNTY to bill Medi-Cal,
and any other third-party source, for services and meet State and Federal reporting requirements.
J. CONTRACTOR must comply with all laws and regulations governing the Federal
Medicare program, including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C. section
1395 et seq; and 2) the regulations and rules promulgated by the Federal Centers for Medicare and
Medicaid Services as they relate to participation, coverage and claiming reimbursement. CONTRACTOR
will be responsible for compliance as of the effective date of each Federal, State or local law or regulation
specified.
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K. If a client has dual coverage, such as other health coverage (OHC) or Federal
Medicare, CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or have
validation of claiming with no response ninety (90) days after the claim was mailed before the service can
be entered into COUNTY’s electronic information system. CONTRACTOR must report all third party
collections for Medicare, third party, client pay, or private pay in each monthly invoice and in the annual
cost report that is required to be submitted. A copy of explanation of benefits or CMS 1500 form is
required as documentation. CONTRACTOR must report all revenue collected from OHC, third-party,
client-pay, or private-pay in each monthly invoice and in the cost report that is required to be submitted.
CONTRACTOR shall submit monthly invoices for reimbursement that equal the amount due
CONTRACTOR less any funding sources not eligible for Federal and State reimbursement.
CONTRACTOR must comply with all laws and regulations governing the Federal Medicare program,
including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2)
the regulation and rules promulgated by the Federal Centers for Medicare and Medicaid Services as they
relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for
compliance as of the effective date of each Federal, State or local law or regulation specified.
L. Data entry shall be the responsibility of CONTRACTOR. COUNTY shall monitor
the volume of services and cost of services entered into COUNTY’s electronic information system. Any
and all audit exceptions resulting from the provision and reporting of specialty mental health services by
CONTRACTOR shall be the sole responsibility of CONTRACTOR. CONTRACTOR will comply with all
applicable policies, procedures, directives and guidelines regarding the use of COUNTY’s electronic
information system.
M. Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR shall comply with any and all requests and directives associated
with COUNTY maintaining State Medi-Cal site certification. CONTRACTOR shall provide specialty mental
health services in accordance with COUNTY’s Mental Health Plan. CONTRACTOR must comply with the
“Fresno County Mental Health Plan Compliance Program and Code of Conduct” set forth in Exhibit D,
attached hereto and incorporated herein by reference and made part of this Agreement. CONTRACTOR
shall comply with any and all requests associated with any State and/or Federal reviews or audits.
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CONTRACTOR may provide direct specialty mental health services using pre-
licensed staff as long as the individual is approved as a provider by the Mental Health Plan, is supervised
by licensed staff, works within his/her scope, and only delivers allowable direct specialty mental health
services. It is understood that each service is subject to audit for compliance with Federal and State
regulations, and that COUNTY may be making payments in advance of said review. In the event that a
service is disapproved, COUNTY may, at its sole discretion, withhold compensation or set off from other
payments due the amount of said disapproved services. CONTRACTOR shall be responsible for audit
exceptions to ineligible dates of services or incorrect application of utilization review requirements.
6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under this
Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’s officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no right to
control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and
function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof.
CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules and
regulations, if any, of governmental authorities having jurisdiction over matters, which are directly or
indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
matters relating to payment of CONTRACTOR’S employees, including compliance with Social Security,
withholding, and all other regulations governing such matters. It is acknowledged that during the term of
this Agreement, CONTRACTOR may be providing services to others unrelated to COUNTY or to this
Agreement.
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7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent of
all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to services, staffing, and responsibilities of
CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health treatment, as
set forth in Exhibit A, may be made with the signed written approval of COUNTY’s DBH Director or
designee and CONTRACTOR through an amendment approved by COUNTY’s County Counsel and the
COUNTY’s Auditor-Controller’s Office.
In addition, changes to expense category (i.e., Salary & Benefits, Facilities/Equipment,
Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, as set forth
in Exhibit B, that do not exceed 10% of the maximum compensation payable to CONTRACTOR may be
made with the written approval of COUNTY’s DBH Director or designee. Changes to the expense
categories in the budget that exceed ten percent (10%) of the maximum compensation payable to
CONTRACTOR, may be made with the signed written approval of COUNTY’s DBH Director or designee
through an amendment approved by COUNTY’s Counsel and COUNTY’s Auditor-Controller’s Office.
Modifications shall not result in any change to the annual maximum compensation amount
payable to CONTRACTOR, as stated in this Agreement.
8. NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties under
this Agreement without the prior written consent of COUNTY.
9. HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents, and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims, and losses occurring or resulting to COUNTY
in connection with the negligent performance, or failure to perform, by CONTRACTOR, its officers,
agents, or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the negligent performance, or failure to
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perform, of CONTRACTOR, its officers, agents, or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10. INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any third
parties, CONTRACTOR, at its sole expense shall maintain in full force and affect the following insurance
policies throughout the term of this Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million Dollars ($2,000,000) per occurrence and an annual aggregate of Four Million Dollars ($4,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific coverages including completed operations, product liability, contractual liability, Explosion-Collapse-Underground (XCU), fire legal liability, or any other liability insurance deemed necessary because of the nature of the Agreement.
B. Automobile Liability
Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or if Consultant has no owned autos, Code 8 (hired) and 9 (non-owned).with limits for bodily injury of not less than Five Hundred Thousand Dollars ($500,000) per person and with limits no less than One Million Dollars ($1,000,000) per accident for bodily injury and property damage. Coverage should include all vehicles used in connection with this Agreement. C. Real and Property Insurance
CONTRACTOR shall maintain a policy of insurance for all risk personal property coverage which shall be endorsed naming the County of Fresno as an additional loss payee. The personal property coverage shall be in an amount that will cover the total of COUNTY purchase and owned property, at a minimum, as discussed in Section Twenty One (21) of this Agreement.
D. All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of COUNTY’S personal property in possession of CONTRACTOR and/or used in the execution of this Agreement. COUNTY will be identified on an appropriate certificate of insurance as the certificate holder and will be named as an Additional Loss Payee on the Property Insurance Policy.
E. Professional Liability
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Professional Liability Insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence, Three Million Dollars ($3,000,000) annual aggregate. CONTRACTOR agrees that it shall maintain, at its sole expense, in full force and effect for a period of three (3) years following the termination of this Agreement, one or more policies of professional liability insurance with limits of coverage as specified herein.
F. Child Abuse/Molestation and Social Services Coverage
CONTRACTOR shall have either separate policies or an umbrella policy with endorsements covering Child Abuse/Molestation and Social Services Liability coverage or have a specific endorsement on their General Commercial liability policy covering Child Abuse/Molestation and Social Services Liability. The policy limits for these policies shall be One Million Dollars ($1,000,000) per occurrence with a Two Million Dollars ($2,000,000) annual aggregate. The policies are to be on a per occurrence basis.
G. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the California Labor Code.
H. Cyber Liability Cyber Liability Insurance, with limits not less than $2,000,000 per occurrence or claim, $2,000,000 aggregate. Coverage shall be sufficiently broad to respond to duties and obligations undertaken by CONTRACTOR in this agreement and shall include, but not be limited to, claims involving infringement of intellectual property, including but not limited to infringement of copyright, trademark, trade dress, invasion of privacy violations, information theft, damage to or destruction of electronic information, release of private information, alteration of electronic information, extortion and network security. The policy shall provide coverage for breach response costs as well as regulatory fines and penalties as well as credit monitoring expenses with limits sufficient to respond to these obligations.
I. Waiver of Subrogation CONTRACTOR hereby grant to COUNTY a waiver of any right to subrogation which any insurer of said CONTRACTOR may acquire against COUNTY by virtue of the payment of any loss under insurance. CONTRACTOR agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not COUNTY has received a waiver of subrogation endorsement from the insurer.
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned. Such coverage
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for additional insured shall apply as primary insurance and any other insurance, or self-insurance,
maintained by COUNTY, its officers, agents, and employees shall be excess only and not contributing with
insurance provided under CONTRACTOR’S policies herein. This insurance shall not be cancelled or
changed without a minimum of thirty (30) days advance written notice given to COUNTY.
Within thirty (30) days from the date CONTRACTOR signs this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 3133 N.
Millbrook Ave, Fresno, California, 93703, Attention: Contracts Division, stating that such insurance
coverages have been obtained and are in full force; that the County of Fresno, its officers, agents, and
employees will not be responsible for any premiums on the policies; that such Commercial General
Liability insurance names the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are concerned;
that such coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents, and employees, shall be excess only and not
contributing with insurance provided under CONTRACTOR’s policies herein; and that this insurance shall
not be cancelled or changed without a minimum of thirty (30) days advance, written notice given to
COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement
upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of California.
Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of A FSC VII or
better.
11. LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff shall
maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for the
provision of the services hereunder and required by the laws and regulations of the United States of
America, State of California, the County of Fresno, and any other applicable governmental agencies.
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CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such
licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of any
appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR’s staff shall comply with all
applicable laws, rules or regulations, as may now exist or be hereafter changed.
12. RECORDS
CONTRACTOR shall maintain records in accordance with Exhibit E, "Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part of
this Agreement. COUNTY shall be allowed to review all records of services provided, including the goals
and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
All mental health records shall be considered the property of the COUNTY and shall be retained by the
COUNTY upon termination or expiration of this Agreement.
13. REPORTS
A. Outcome Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
reasonably requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to
change at COUNTY’s DBH discretion.
B. Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
data, and other information as COUNTY’s DBH may reasonably request pertaining to matters covered by
this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments until
there is compliance. In addition, CONTRACTOR shall provide written notification and explanation to
COUNTY within five (5) days of any funds received from another source to conduct the same services
covered by this Agreement.
C. Cost Report
CONTRACTOR shall provide financial data to identify all direct and indirect costs
incurred by CONTRACTOR for all services delivered under this Agreement. All Cost Reports must be
prepared in accordance with Generally Accepted Accounting Principles (GAAP) and Welfare and
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Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3) and 5718(c). Unallowable costs such as lobbying or
political donations must be deducted on the cost report and monthly invoice reimbursements.
D. Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
agree to settle dollar amounts disallowed or settled in accordance with DHCS audit settlement findings
related to the reimbursement provided under this Agreement. CONTRACTOR will participate in the
several phases of settlements between COUNTY/CONTRACTOR and DHCS. The phases of initial cost
reporting for settlement according to State reconciliation of records for paid Medi-Cal services and audit
settlement are: State DHCS audit 1) initial cost reporting – after an internal review by COUNTY, the
COUNTY files the cost report with State DHCS on behalf of CONTRACTOR’s legal entity for the fiscal
year; 2) Settlement – State reconciliation of records for paid Medi-Cal services, approximately 18 to 36
months following the State close of the fiscal year, DHCS will send notice for any settlement under this
provision to COUNTY; and 3) Audit Settlement-State DHCS audit. After final reconciliation and settlement
DHCS may conduct a review of medical records, cost report along with support documents submitted to
COUNTY in initial submission to determine accuracy and may disallow costs and/or units of services.
COUNTY may choose to appeal and therefore reserves the right to defer payback settlement with
CONTRACTOR until resolution of the appeal. DHCS Audits will follow Federal Medicaid procedures for
managing overpayments. If at the end of the Audit Settlement, COUNTY determines that it overpaid
CONTRACTOR, it will require CONTRACTOR to repay the Medi-Cal related overpayment back to
COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification by COUNTY,
or COUNTY shall withhold future payments until all excess funds have been recouped by means of an
offset against any payments then or thereafter owing to COUNTY under this or any other Agreement
between the COUNTY and CONTRACTOR.
14. MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director, and the
State Department of Health Care Services or their designees, the right to review and monitor records,
services, or procedures, at any time, in regard to clients, as well as the overall operation of
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CONTRACTOR’s performance, in order to ensure compliance with the terms and conditions of this
Agreement.
15. REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended during
the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of
such amendment.
16. COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department Health Care Services, and that under said agreement
the State imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall adhere
to all State requirements, including those identified in Exhibit F, “State Mental Health Requirements”,
attached hereto and by this reference incorporated herein and made part of this Agreement.
CONTRACTOR shall also file an incident report for all incidents involving clients, following the Protocol and
using the W orksheet identified in Exhibit G, “Incident Reporting”, attached hereto and by this reference
incorporated herein and made part of this Agreement, or a protocol and worksheet presented by
CONTRACTOR that is accepted by COUNTY’s DBH Director or designee.
17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall perform all services as set forth in Exhibit A in accordance with the
Assertive Community Treatment Model and in alignment with “Medi-Cal Organizational Provider
Standards”, as set forth in Exhibit H, attached hereto and by this reference incorporated herein and made
part of this Agreement.
CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health
Plan as described in Exhibit I, “Fresno County Mental Health Plan”, attached hereto and by this reference
incorporated herein and made part of this Agreement.
18. CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
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19. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder
by the U.S. Department of Health and Human Services (HIPAA Regulations) and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as
set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code of
Federal Regulations.
20. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into
a contractual relationship with COUNTY for the purpose of providing services under this Agreement must
employ adequate data security measures to protect the confidential information provided to
CONTRACTOR by COUNTY, including but not limited to the following:
A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1) CONTRACTOR has received authorization by COUNTY for telecommuting
purposes;
2) Current virus protection software is in place;
3) Mobile device has the remote wipe feature enabled; and
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4) A secure connection is used.
B. CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring contractor-owned computers or computer
peripherals into COUNTY for use without prior authorization from 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 encrypted and stored on a secure server approved by COUNTY and transferred
by means of a Virtual Private Network (VPN) connection, or another type of secure connection.
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on non-
County premises without prior authorization from COUNTY’s Chief Information Officer and/or designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the integrity
and security of COUNTY’s confidential information and prevent unauthorized access, viewing, use, or
disclosure of data maintained in computer files, program documentation, data processing systems, data
files, and data processing equipment which stores or processes COUNTY data internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
BIT or higher. Additionally, a password or pass phrase must be utilized.
G. CONTRACTOR is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data maintained
in computer files, program documentation, data processing systems, data files and data processing
equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information provided to
CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as
required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be
responsible for all costs incurred as a result of providing the required notification.
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21. PROPERTY OF COUNTY
A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items will
be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1. Have life span of over one year;
2. Is not a repair part; and
3. Must be valued at or greater than the capitalization thresholds for the asset
type.
Asset Type Threshold
• Land $0 • Buildings and improvements $100,000 • Infrastructure $100,000 • Tangible $5,000 o Equipment o Vehicles
• Intangible $100,000 o Internally generated software o Purchased software o Easements o Patents
• Capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
approved and identified as an asset, it will be tagged with a COUNTY program number. A Fixed Asset
Log will be maintained by COUNTY’s Asset Management System and annually inventoried until the asset
is fully depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be
inventoried in comparison to COUNTY’s DBH Asset Inventory System.
B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are sensitive
assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and other
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sensitive items as determined by COUNTY’s DBH Director or designee. CONTRACTOR will maintain a
tracking system on the items and are not required to be capitalize or depreciated. The items are subject to
annual inventory for compliance.
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in an
annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of this
Agreement, CONTRACTOR shall be physically present when fixed and inventoried assets are returned to
COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY-owned
undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1. Maintain all items of equipment in good working order and condition, normal
wear and tear is expected;
2. Label all items of equipment with COUNTY assigned program number,
perform periodic inventories as required by COUNTY, and maintain an inventory list showing where and
how the equipment is being used, in accordance with procedures developed by COUNTY. All such lists
shall be submitted to COUNTY within ten (10) days of any request therefore; and
3. Report in writing to COUNTY immediately after discovery, the loss or theft of
any items of equipment. For stolen items, the local law enforcement agency must be contacted and a
copy of the police report submitted to COUNTY.
D. The purchase of any equipment by CONTRACTOR with funds provided hereunder
shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of this Agreement as
appropriate, and must be directly related to CONTRACTOR’S services or activities under the terms of this
Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from equipment
purchased, which are incurred by CONTRACTOR, if prior written approval has not been obtained from
COUNTY.
E. CONTRACTOR must obtain prior written approval from COUNTY’s DBH whenever
there is any modification or change in the use of any property acquired or improved, in whole or in part,
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using funds under this Agreement. If any real or personal property acquired or improved with said funds
identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value
of the property, less any portion thereof attributable to expenditures of funds not provided under this
Agreement. These requirements shall continue in effect for the life of the property. In the event this
Agreement expires, or terminates, the requirements for this Section shall remain in effect for activities or
property funded with said funds, unless action is taken by the State government to relieve COUNTY of
these obligations.
22. NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services because of race,
religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age, or sex,
pursuant to all applicable State and Federal statutes and regulations.
23. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45 C.F.R. Part
80) and Executive Order 12250 of 1979, which prohibits recipients of federal financial assistance from
discriminating against persons based on race, color, national origin, sex, disability, or religion. This is
interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive and quality bilingual
services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients, including, but not limited to, assessing the
cultural and linguistic needs of its clients, training of staff on the policies and procedures, and monitoring its
language assistance program. CONTRACTOR’s procedures must include ensuring compliance of any
sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
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persons participating in CONTRACTOR’s services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be provided
as necessary to allow such participants meaningful access to the programs, services and benefits provided
by CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR’s “vital
documents” (those documents that contain information that is critical for accessing CONTRACTOR’s
services or are required by law) shall be provided to participants at no cost to the participant.
CONTRACTOR 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 preferred language and can effectively
communicate any specialized terms and concepts peculiar to CONTRACTOR’s services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
standards as published by the Office of Minority Health, CONTRACTOR must submit to COUNTY for
approval, within sixty (60) days from date of execution of this Agreement, CONTRACTOR’s plan to
address all national cultural competency standards as set forth in Exhibit J “National Standards on
Culturally and Linguistically Appropriate Services (CLAS)”, attached hereto and incorporated herein by
reference and made part of this Agreement. COUNTY’s annual on-site review of CONTRACTOR shall
include collection of documentation to ensure all national standards are implemented. As the national
competency standards are updated, CONTRACTOR’s cultural competency plan must be updated
accordingly. Cultural competency training for CONTRACTOR’s staff should be substantively integrated
into health professions education and training at all levels, both academic and functional, including core
curriculum, professional licensure, and continuing professional development programs. CONTRACTOR,
on a monthly basis, shall provide COUNTY’s DBH a monthly monitoring tool/report that shows all
CONTRACTOR’s staff completed cultural competency trainings.
24. AMERICANS WITH DISABILITIES ACT
CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to
this Agreement, shall comply with the accessibility requirements of Section 508 of the Rehabilitation Act
and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. § 794 (d)), and regulations
implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998,
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Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic and
information technology (EIT) accessible to people with disabilities. California Government Code section
11135 codifies section 508 of the Act requiring accessibility of electronic and information technology.
25. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon
written request to the Secretary of the United States Department of Health and Human Services, or upon
request to the Comptroller General of the United States General Accounting Office, or any of their duly
authorized representatives, a copy of this Agreement and such books, documents, and records as are
necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR under
this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any of its
duties under this Agreement through a subcontract, with a value or cost of Ten Thousand and No/100
Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such Agreement
shall contain a clause to the effect that until the expiration of four (4) years after the furnishing of such
services pursuant to such subcontract, the related organizations shall make available, upon written request
to the Secretary of the United States Department of Health and Human Services, or upon request to the
Comptroller General of the United States General Accounting Office, or any of their duly authorized
representatives, a copy of such subcontract and such books, documents, and records of such organization
as are necessary to verify the nature and extent of such costs.
26. SINGLE AUDIT CLAUSE
A. If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars ($750,000.00)
or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in
accordance with the requirements of the Single Audit Standards as set forth in Office of Management and
Budget (OMB) Circular A-133. CONTRACTOR shall submit said audit and management letter to
COUNTY. The audit must include a statement of findings or a statement that there were no findings. If
there were negative findings, CONTRACTOR must include a corrective action plan signed by an
authorized individual. CONTRACTOR agrees to take action to correct any material non-compliance or
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weakness found as a result of such audit. Such audit shall be delivered to COUNTY’s DBH Business
Office for review within nine (9) months of the end of any fiscal year in which funds were expended and/or
received for the program. Failure to perform the requisite audit functions as required by this Agreement
may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option, contracting with a
public accountant to perform said audit, or may result in the inability of COUNTY to enter into future
agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR.
B. A single audit report is not applicable if CONTRACTOR’s Federal contracts do not
exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR’s only
funding is through Drug related Medi-Cal. If a single audit is not applicable, a program audit must be
performed and a program audit report with management letter shall be submitted by CONTRACTOR to
COUNTY as a minimum requirement to attest to CONTRACTOR solvency. Said audit report shall be
delivered to COUNTY’s DBH Business Office for review no later than nine (9) months after the close of the
fiscal year in which the funds supplied through this Agreement are expended. Failure to comply with this
Act may result in COUNTY performing the necessary audit tasks or contracting with a qualified accountant
to perform said audit. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or
weakness found as a result of such audit. Audit work performed by COUNTY under this paragraph shall
be billed to CONTRACTOR at COUNTY cost, as determined by COUNTY’s Auditor-Controller/Treasurer-
Tax Collector.
C. CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal
Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
least three (3) years following final payment under this Agreement or the closure of all other pending
matters, whichever is later.
27. COMPLIANCE
CONTRACTOR agrees to comply with COUNTY’s Contractor Code of Conduct and Ethics
and the COUNTY’s Compliance Program in accordance with Exhibit D. Within thirty (30) days of entering
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into this Agreement with COUNTY, CONTRACTOR shall have all of CONTRACTOR’s employees, agents,
and subcontractors providing services under this Agreement certify in writing, that he or she has received,
read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall
ensure that within thirty (30) days of hire, all new employees, agents, and subcontractors providing
services under this Agreement shall certify in writing that he or she has received, read, understood, and
shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR understands that the
promotion of and adherence to the Contractor Code of Conduct is an element in evaluating the
performance of CONTRACTOR and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents, and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents, and subcontractors shall complete documentation
and billing or billing/reimbursement training. All new employees, agents, and subcontractors shall attend
the appropriate training within thirty (30) days of hire. Each individual who is required to attend training
shall certify in writing that he or she has received the required training. The certification shall specify the
type of training received and the date received. The certification shall be provided to COUNTY’s
Compliance Officer at 3133 N. Millbrook, Fresno, California 93703. CONTRACTOR agrees to reimburse
COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result
of CONTRACTOR’s violation of the terms of this Agreement.
28. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither they, nor any of their
officers, are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs; that neither they, nor any of their officers, have been convicted of a criminal
offense related to the provision of health care items or services; nor have they, nor any of their officers,
been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
debarment, or ineligibility. If COUNTY learns, subsequent to entering into a contract, that CONTRACTOR
is ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility for, or involvement
with, COUNTY’s business operations related to the Federal Health Care Programs and shall remove such
CONTRACTOR from any position in which CONTRACTOR’s compensation, or the items or services
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rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by
Federal Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR
is reinstated into participation in the Federal Health Care Programs.
A. If COUNTY has notice that either CONTRACTOR, or its officers, have been
charged with a criminal offense related to any Federal Health Care Program, or are proposed for exclusion
during the term of any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure
the accuracy of any claims submitted to any Federal Health Care Program. At its discretion, given such
circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of the
charges or the proposed exclusion.
B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services 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 (3) they have
been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
debarment, or ineligibility.
1. In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred, or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
2. Notwithstanding the above, COUNTY, at its discretion, may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended, or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
C. CONTRACTOR shall verify (by asking the applicable employees and
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subcontractors) that all current employees and existing subcontractors who, in each case, are expected to
perform professional services under this Agreement (1) are not currently excluded, suspended, debarred,
or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted of a
criminal offense related to the provision of health care items or services; and (3) have not been reinstated
to participate in the Federal Health Care Program after a period of exclusion, suspension, debarment, or
ineligibility. In the event any existing employee or subcontractor informs CONTRACTOR that he or she is
excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs,
or has been convicted of a criminal offense relating to the provision of health care services,
CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
relating to services provided to COUNTY.
1. CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is
providing professional services under this Agreement is excluded, suspended, debarred, or otherwise
ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
to the provision of health care services.
2. Notwithstanding the above, COUNTY, at its discretion, may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended, or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating to
CONTRACTOR’s compliance with the provisions of this Section.
E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation of
CONTRACTOR’s obligations as described in this Section.
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29. PUBLICITY PROHIBITION
None of the funds, materials, property or services provided directly or indirectly under this
Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e., purchasing of
tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the above,
publicity of the services described in Section One (1) of this Agreement shall be allowed as necessary to
raise public awareness about the availability of such specific services when approved in advance by
COUNTY’s DBH Director or designee and at a cost to be provided in Exhibit B for such items as
written/printed materials, the use of media (i.e., radio, television, newspapers), and any other related
expense(s).
30. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client or a
client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (l0th) day of the following month,
in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and attach
documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of their
right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to
State licensing bodies that affect COUNTY clients within twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY clients,
CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
the complaint, the complaint and CONTRACTOR’S disposition of, or corrective action taken to resolve the
complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit I.
CONTRACTOR shall file an incident report for all incidents involving clients, following the protocol and
using the worksheet identified in Exhibit G.
31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is disclosing entities, fiscal agents, or
managed care entities, 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),
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the following information must be disclosed by CONTRACTOR by completing Exhibit K, “Disclosure of
Ownership and Control Interest Statement”, attached hereto and by this reference incorporated herein and
made part of this Agreement. CONTRACTOR shall submit this form to the COUNTY’s DBH within thirty
(30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any changes to
this information within thirty-five (35) days of occurrence by completing Exhibit K. Submissions shall be
scanned pdf copies and are to be sent via email to COUNTY’s assigned Staff Analyst with the DBH
Contracts Division.
32. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them, their
owners, officers, corporate managers, and partners (hereinafter collectively referred to in this Section as
“CONTRACTOR”):
A. Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1. Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction;
2. Violation of a federal or state antitrust statute;
3. Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
or
4. False statements or receipt of stolen property.
B. Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR from
further business consideration. The information will be considered as part of the determination of whether
to continue and/or renew this Agreement and any additional information or explanation that
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that CONTRACTOR failed to disclose required information, any contract awarded to such CONTRACTOR
may be immediately voided and terminated for material failure to comply with the terms and conditions of
the award.
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CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit L, attached hereto
and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
must immediately advise COUNTY’s DBH in writing if, during the term of this Agreement: (1)
CONTRACTOR becomes suspended, debarred, excluded, or ineligible for participation in Federal or State
funded programs or from receiving federal funds as listed in the excluded parties’ list system
(http://www.epls.gov); or (2) any of the above listed conditions become applicable to CONTRACTOR.
CONTRACTOR shall indemnify, defend, and hold 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.
33. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if a CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, CONTRACTOR changes its status
to operate as a corporation.
Members of CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services under
this Agreement. A self-dealing transaction shall mean a transaction to which CONTRACTOR is a party
and in which one or more of its directors has a material financial interest. Members of the Board of
Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a
“Self-Dealing Transaction Disclosure Form”, attached hereto as Exhibit M and incorporated herein by
reference and made part of this Agreement, and submitting it to COUNTY prior to commencing with the
self-dealing transaction or immediately thereafter.
34. AUDITS AND INSPECTIONS
CONTRACTOR shall, at any time during business hours and as often as COUNTY may
deem necessary, make available to COUNTY for examination all of its records and data with respect to the
matters covered by this Agreement. CONTRACTOR shall, upon request by COUNTY, permit COUNTY to
audit and inspect all such records and data necessary to ensure CONTRACTOR’s compliance with the
terms of this Agreement.
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If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period of
three (3) years after final payment under contract (California Government Code section 8546.7).
35. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR Director, Fresno County Comprehensive Youth Services Department of Behavioral Health of Fresno, Inc. 3133 N. Millbrook Ave 4545 N. West Avenue Fresno, CA 93702 Fresno, CA 93705
All notices between COUNTY and CONTRACTOR provided for or permitted under this
Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three (3) COUNTY business days after deposit in the United States mail, postage prepaid,
addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
(1) COUNTY business day after deposit with the overnight commercial courier service, delivery fees
prepaid, with delivery instructions given for next day delivery, addressed to the recipient. A notice
delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if such
transmission is completed outside of COUNTY business hours, then such delivery shall be deemed to be
effective at the next beginning of a COUNTY business day), provided that the sender maintains a machine
record of the completed transmission. For all claims arising out of or related to this Agreement, nothing in
this section establishes, waives, or modifies any claims presentation requirements or procedures provided
by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government
Code, beginning with section 810).
36. GOVERNING LAW
Venue for any action arising out of or related to the Agreement shall only be in Fresno
County, California.
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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.
37. SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of any
one provision in the Agreement shall not affect the other provisions.
38. ENTIRE AGREEMENT
This Agreement, including all Exhibits, Revised RFP No. 18-036 and CONTRACTOR’s
Response thereto, constitutes the entire agreement between CONTRACTOR and COUNTY with respect
to the subject matter hereof and supersedes all previous agreement negotiations, proposals,
commitments, writings, advertisements, publications, and understandings of any nature whatsoever unless
expressly included in this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day
2 and year first hereinabove written.
3
4 COMPREHENSIVE YOUTH SERVICES
OF FRESNO, INC.
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o15?!€AJ . UUi=~
(;egno , CfJ °t37D5
Mailing Address
FOR ACCOUNTING USE ONLY:
ORG No .: 56304321
Account No .: 7295
Requisition No.:
35
COUNTY OF FRESNO
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
Exhibit A
Page 1 of 8
Department of Behavioral Health
Functional Family Therapy Services to Children/Youth
SUMMARY OF SERVICES
PROVIDER: Comprehensive Youth Services of Fresno, Inc.
4545 N. West Avenue
Fresno, CA 93705
CONTRACT TERM: January 1, 2019 - June 30, 2019
July 1, 2019 - June 30, 2020
July 1, 2020 - June 30, 2021
July 1, 2021 - June 30, 2022
July 1, 2022 - June 30, 2023
I. SCHEDULE OF SERVICES:
Services for Functional Family Therapy, a Prevention and Early Intervention (PEI) program,
under this Agreement, will be available to clients and their families during the hours of 7:00am-
8:00pm Monday - Friday. Additional services will be provided after the standard hours of
operation and on weekends as needed to address client concerns and/or provide services to
client who are unavailable for services during standard business hours.
II. TARGET POPULATION:
The target population is youth, ages 11-18 years, who are at-risk of involvement or are currently
involved in the juvenile justice system, and have a significant family conflict. Additionally,
services shall be provided to clients/families in rural/metro areas; to clients/families that have no
or limited means of payment for services; to clients/families who have traditionally been
reluctant to seek services from traditional mental health setting; and to clients/families who are
in danger of homelessness, hospitalizations, out of home placements, or emergency room
visits.
The program will serve a minimum of 450 unduplicated identified clients within each 12-month
period of this Agreement. In addition, identified clients’ siblings, other relatives, caregivers, and
other significant support person may participate and receive specialty mental health services
from this program.
III. PROJECT DESCRIPTION:
Comprehensive Youth Services of Fresno, Inc. (CYS) will provide services to the target
population under the Mental Health Services ACT (MHSA) PEI framework. Services to youth
referred to this program will be provided within the parameters mentioned below.
Parents/caregivers and other members of the family may be assessed for treatment needs, and
provided services as needed, or may be linked to other treatment programs or community
resources to meet each individual’s needs. Services are conducted in both clinic and home
settings, and can also be provided in a variety of settings including schools, child welfare
facilities, probation and parole offices/aftercare systems, and mental health facilities.
Exhibit A
Page 2 of 8
Intake and Initial Assessment
Youth may be referred to this program through various sources including, but not limited to,
COUNTY’s Family Behavioral Health Court, Probation, Department of Behavioral Health (DBH),
Department of Social Services (DSS), schools, other community-based organizations, or as
requested by parents and other caregivers.
DBH clients will be prioritized; Contractor will be responsible for contacting County DBH first
whenever an opening becomes available. CONTRACTOR will contact the family of the referred
youth within 24 hours of receipt of the referral to determine if it is appropriate for the youth and
family to receive FFT services under this Agreement. If services are appropriate, an initial
intake/assessment will be scheduled no later than 10 days from the initial contact.
Termination and Discharge
Client discharge is determined on a case-by-case basis, with regard to the youth’s progress
toward individualized treatment goals. Reasons for discharge include FFT no longer meets the
needs of the youth and family; youth and family have met treatment goals; lack of progress; lack
of participation; and/or the client has aged out of the program.
Evidence-Based Practices
Evidence-based practices (EBP) utilized in FFT include Engagement in Change, Motivation to
Change, Relational/Interpersonal Assessment and Planning for Behavior Change, Behavior
Change, and Generalization Across Behavioral Domains and Multiple Systems.
IV. CONTRACTOR RESPONSIBILITIES:
CONTRACTOR shall:
A. CONTRACTOR shall carefully adhere to the principles of FFT evidence-based practice
model and procedures, as well as the competent delivery of the model.
B. CONTRACTOR shall participate in continuing training and technical assistance with a
certified agency that can provide clinical oversight of the delivery of the FFT model.
C. Develop, coordinate, and provide formal and informal supports and services for the client
and family, as well as develop or expand parent advocacy and support network.
D. Institute mental health treatment models other than those listed above, as needed, to
meet the mental health treatment needs of the children and families engaged in services
offered through this Agreement.
E. Provide Intensive Care Coordination (ICC) and Intensive Home-Based Services (IHBS)
when medically necessary.
F. Provide services in alignment with the Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery, as defined in Exhibit C.
G. Provide services in accordance with national standards for Culturally and Linguistically
Appropriate Services (CLAS), as defined in Exhibit J.
Exhibit A
Page 3 of 8
H. Ensure that written policies and procedures guides (PPG), as they relate to this
Agreement, are up to date, and available to be shared with COUNTY, upon
request.
I. Measure and report client and system outcomes consistent with the COUNTY’s MHSA
Plan requirements.
J. Provide parenting groups that are conducted in the preferred language of the participant
client/families.
K. Maintain appropriate client to staff ratios with job classifications, responsibilities, and
licensure/certification, as recommended or required by MHSA FSP standards.
L. Provide the following staffing components, at minimum:
1. Licensed or license-eligible therapists: Provide evidenced-based clinical
treatment. At least one of the therapist positions will be occupied by a former client or
family member with comparable experience to the child and family receiving services. At
least one of the therapist positions shall be occupied by a licensed clinician with
advanced training in infant mental health in order to provide adequate oversight. These
positions shall be recruited based on linguistic and cultural needs of the targeted
population (e.g., Latino, Southeast Asian, African American, Native American, and/or
SED).
2. Licensed or license-eligible therapists: Provide linkages and therapeutic services to
enrolled children and their caregivers as identified in the individual services and supports
plan.
3. Care manager or parent partner: Provide direct services to children and families
including home visitation, case management, outreach, community resource information
and referral
M. Facilitate extensive community resource development and outreach to increase access
to and awareness of program services through participation in community resource fairs,
public presentations, distribution of informational materials, one-on-one communications
with community partners, visits to local schools and daycare centers.
N. Provide outreach and education to referring agencies to assist those agencies as they
determine appropriate resources for clients in need of services.
O. Utilize targeted outreach strategies to reach harder to engage communities, such as the
Native American population and rural communities.
P. Secure the services of trained translators/interpreters as may be necessary.
Q. Develop a plan to continually engage targeted populations.
R. Distribute literature/informational brochures in appropriate languages and request
feedback as to how access to care could be improved for these culturally diverse
communities.
Exhibit A
Page 4 of 8
V. COUNTY RESPONSIBILITIES:
COUNTY shall:
A. Provide oversight, through its MHSA Coordinator or designee, and collaborate with
CONTACTOR and other COUNTY Departments and community agencies to help achieve
State program goals and outcomes. Oversight includes, but is not limited to, contract
monitoring and coordination with the State Department of Health Care Services in regard to
program administration and outcomes.
B. Assist CONTRACTOR in making linkages with the total mental health system of care.
This will be accomplished through regularly scheduled meetings as well as formal and
informal consultation.
C. Participate in evaluating overall program progress and efficiency, and be available to
CONTRACTOR for ongoing consultation.
D. Gather outcome information from target client groups and CONTRACTOR throughout
each term of this Agreement. COUNTY shall notify CONTRACTOR when its participation is
required. The performance outcome measurement process will not be limited to survey
instruments but will also include, as appropriate, client and staff interviews, chart reviews,
and other methods of obtaining required information.
E. Assist CONTRACTOR’S efforts toward cultural and linguistic competency by providing
the following to CONTRACTOR:
1. Technical assistance and training regarding cultural competency requirements at no
cost to CONTRACTOR.
2. Mandatory cultural competency training for CONTRACTOR’s personnel, on an annual
basis, at minimum.
3. Technical assistance for translating information into COUNTY’s threshold languages
(Spanish and Hmong). Translation services and costs associated will be the
responsibility of CONTRACTOR.
VI. PERFORMANCE MEASUREMENT:
CONTRACTOR shall meet or exceed the outcome goals stated in the tables below:
Goal/Objective 1: Increase the delivery of mental health treatment services to
unserved and underserved clients and families with limited or
no means of payment.
Outcome 1A: FFT PEI program services shall be provided to clients and
families with limited or no means of payment.
Exhibit A
Page 5 of 8
Outcome Indicator
1A:
More than 50% of clients/families receiving FFT PEI program
services shall have limited or no means of payment for mental
health services as indicated by the payer sources identified for
the clients on monthly client rosters and program reports.
Outcome 1B: FFT PEI program services shall be provided to clients/families
in rural Fresno County areas.
Outcome Indicator
1B:
More than 50% of the clients/families receiving FFT PEI
program services shall reside in rural Fresno County areas as
indicated by the zip codes identified for clients on monthly
client rosters and program reports (client rosters should include
client demographic data, e.g., age, gender, residence, etc.;
and client utilization data, e.g., quantity/quality of services
delivered).
Goal/Objective 2: Identify and build upon individual and family strengths and
assets to help parents and children develop new skills to
enhance family cohesion.
Outcome 2: Clients will gain skills to reduce family conflict and the ability to
identify familial strengths.
Outcome Indicator 2: 75% of clients/families completing the FFT program will report
an increase in family cohesion as measured by Client Outcome
Measurement tools and Outcome Questionnaires.
Goal/Objective 3: Improve functioning of clients completing the FFT PEI
program.
Outcome 3: Clients will gain self confidence, increased ability to handle
anger and manage difficult situations, and experience
improved individual functioning.
Outcome Indicator
3A:
85% of the clients that participate in the FFT PEI program will
report functional improvement measured by CANS
(Child/Adolescent Needs and Strengths) scores.
Outcome Indicator
3B:
50% of the clients that complete the FFT PEI program will
report a decrease in school problems between start of program
and end of program.
Outcome Indicator
3C:
50% of the clients that complete the FFT PEI program will
report a decrease in inpatient mental health crisis visits
between start of program and end of program.
Outcome Indicator
3D:
50% of the clients that complete the FFT PEI program will
report a decrease in recidivism into the Juvenile Justice
System between start of program and end of program.
Exhibit A
Page 6 of 8
Outcome Indicator
3E:
85% of the clients participating in the FFT PEI program that are
diagnosed with mental health disorders, e.g., conduct disorder,
oppositional defiant disorder, disruptive behavior disorder, etc.,
when they begin the FFT PEI program will report improvement
after successfully completing the program.
Goal/Objective 4: Ensure clients/families are actively engaged in the FFT PEI
program.
Outcome 4: Clients/families will indicate satisfaction with FFT PEI program
services they receive.
Outcome Indicator 4: At a minimum, 80% percent of clients/families will report their
satisfaction with program services on the CONTRACTOR’s
consumer satisfaction surveys, and the semi-annual State POQI
survey.
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or at the risk of, mental illness
and/or substance use disorders through the cultivation of strengths toward promoting recovery
in the least restrictive environment.
CONTRACTOR shall provide either existing or sample measureable outcomes reports. The
CONTRACTOR will be required to submit measureable outcomes on an annual basis, as
identified in the Departments Policy and Procedure Guide (PPG) 1.2.7 Performance Outcomes
Measures, attached hereto to this RFP as Exhibit D. Performance outcomes measures must be
approved by the Department and satisfy all State and local mandates. The Department will
provide technical assistance and support in defining measureable outcomes. All performance
indicators will reflect the four domains identified by the Commission Accreditation of
Rehabilitation Facilities (CARF). The domains are Effectiveness, Efficiency, Access, and
Satisfaction. These are defined and listed below.
The Fresno County Department of Behavioral Health collects data about the characteristics
of the persons served and measures service delivery performance indicators in each of the
following CARF DOMAINS: At minimum, one performance indicator will be identified for
each of the four CARF domains listed below.
1. Effectiveness: A performance dimension that assesses the degree to which an
intervention or services have achieved the desired outcome/result/quality of care through
measuring change over time. The results achieved and outcomes observed are for
persons served.
Examples of indicators include: Persons get a job with benefits, or receive supports needed
to live in the community, increased function, activities, or participation, and improvement of
health, employment/earnings, or plan of care goal attainment.
2. Efficiency: Relationship between results and resources used, such as time, money, and
staff. The demonstration of the relationship between results and the resources used to
achieve them. A performance dimension addressing the relationship between the
outputs/results and the resources used to deliver the service.
Exhibit A
Page 7 of 8
Examples of indicators include: Direct staff cost per person served, amount of time it takes
to achieve an outcome, gain in scores per days of service, service hours per person
achieving some positive outcome, total budget (actual cost) per person served, length of
stay and direct service hours of clinical and medical staff.
3. Access: Organizations’ capacity to provide services of those who desire or need
services. Barriers or lack thereof for persons obtaining services. The ability of clients to
receive the right service at the right time. A performance dimension addressing the
degree to which a person needing services is able to access those services.
Examples of indicators include: Timeliness of program entry (From 1st request for service to
1st service), ongoing wait times/wait lists, minimizing barriers to getting services, and no-
show/cancellation rates.
4. Satisfaction: Satisfaction Measures are usually orientated towards consumers, family,
staff, and stakeholders. The degree to which clients, the County and other stakeholders
are satisfied with services. A performance dimension that describes reports or ratings
from persons served about services received from an organization.
Examples of indicators include: opinion of persons served or other key stakeholders in
regards to access, process, or outcome of services received, Consumer and/or Treatment
Perception Survey.
Final selected measures will be agreed upon in contract negotiations along with liquidated
damages. CONTRACTOR must address each of the categories referenced above and may
additionally propose other performance and outcome measures that are deemed best to
evaluate the services provided to clients and/or to evaluate overall program performance.
DBH may adjust the performance and outcome measures periodically throughout the
duration of the agreement, as needed, to best measure the program as determined by
County. CONTRACTOR will be required to utilize and integrate clinical tools as directed by
DBH.
CONTRACTOR must utilize a computerized tracking system with which performance and
outcome measures and other relevant data, such as demographics, will be maintained. The
data tracking system may be incorporated into the CONTRACTOR’S Electronic Health
Record (EHR) or be a stand-alone database. DBH must be afforded read-only access to
the data tracking system, if applicable. DBH prefers that the CONTRACTOR utilize our
current EHR (Avatar) with full access being provided by DBH. However, if the
CONTRACTOR is unable or unwilling to utilize our current EHR, arrangements must be
made to ensure that an interface to transfer all necessary reporting and outcome information
is developed to meet the needs of DBH.
VII.REPORTS:
A. CONTRACTOR shall prepare an evaluation report annually, which will be submitted to
COUNTY’s DBH and made available to partnering and interested local agencies and
organizations (e.g., project collaborators, other community agencies, and mental health
treatment providers). Annual evaluation reports will include the following information:
Exhibit A
Page 8 of 8
demographics of the target population served, services provided to each participant, number
of hospitalizations, enrollment in school, results of data analysis compared to planned
process, output and outcome measures, barriers to program implementation and measures
taken to overcome those barriers, accomplishments of program participants, lessons
learned, and the final result of any and all satisfactory survey(s).
B. CONTRACTOR shall be expected to comply with all contract monitoring and compliance
protocols, procedures, data collection methods, and reporting requirements conducted by
COUNTY.
C. Additional reports and outcome information may be requested by COUNTY at a later
date, as needed.
FTE %Admin Direct Total
0001 FFT Team Site Supervisors 2.00 -$ 94,837$ 94,837$
0002 Clinical Director 0.40 -$ 22,530$ 22,530$
0003 Clinical Oversight/Peer Review 0.30 -$ 20,269$ 20,269$
0004 Community Mental Health Specialists 14.00 -$ 353,316$ 353,316$
0005 Care Managers/Parent Partner 4.00 -$ 84,997$ 84,997$
0006 Finance Dir/HR Mgr/Finance & Clerical Support Varies 18,152$ 37,738$ 55,890$
SALARY TOTAL 18,152$ 613,687$ 631,839$
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 1,389$ 46,948$ 48,337$
0032 SUI 341$ 9,442$ 9,783$
PAYROLL TAX TOTAL 1,730$ 56,390$ 58,120$
0040 Retirement 811$ 27,318$ 28,129$
0041 Workers Compensation 186$ 7,491$ 7,677$
0042 2,030$ 85,953$ 87,983$
EMPLOYEE BENEFITS TOTAL 3,027$ 120,762$ 123,789$
813,748$
1010 Rent/Lease Building 64,949$
1011 Rent/Lease Equipment 20,592$
1012 Utilities 17,825$
1013 Building Maintenance 8,096$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 111,462$
FACILITIES/EQUIPMENT EXPENSES:
FUNCTIONAL FAMILY THERAPY SERVICES
COMPREHENSIVE YOUTH SERVICES OF FRESNO, INC.
6 months: January 1, 2019 - June 30, 2019
Budget Categories -Total Proposed Budget
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
PAYROLL TAXES:
EMPLOYEE BENEFITS:
Health Insurance (medical, vision, life, dental)
SALARY & BENEFITS GRAND TOTAL
Exhibit B
Page 1 of 15
1060 Telephone 10,378$
1061 Answering Service -$
1062 Postage -$
1063 Printing/Reproduction 300$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 12,851$
1067 Household Supplies -$
1068 Food 1,200$
1069 Program Supplies - Therapeutic 5,000$
1070 Program Supplies - Medical -$
1071 Transportation of Clients -$
1072 Staff Mileage/vehicle maintenance 24,713$
1073 Staff Travel (Out of County)8,240$
1074 Staff Training/Registration 23,711$
1075 Lodging 8,250$
1076 Other - (Identify)-$
1077 Other - (Identify)-$
OPERATING EXPENSES TOTAL 94,643$
1080 Accounting/Bookkeeping -$
1081 External Audit 2,926$
1082 Liability Insurance -$
1083 Administrative Overhead 8,197$
1084 Payroll Services 2,880$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 14,003$
1090 Consultant 2,632$
1091 Translation Services 1,000$
1092 Medication Supports 375$
SPECIAL EXPENSES TOTAL 4,007$
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Leased Automobile 2,520$
FIXED ASSETS TOTAL 2,520$
OPERATING EXPENSES:
FINANCIAL SERVICES EXPENSES:
SPECIAL EXPENSES (Consultant/Etc.):
FIXED ASSETS:
Exhibit B
Page 2 of 15
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)8,000$
2002.2 Client Transportation & Support (SFC 72)1,000$
2002.3 Education Support (SFC 72)1,800$
2002.4 Employment Support (SFC 72)800$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
11,600$
TOTAL PROGRAM EXPENSES 1,051,983$
Units of Service Rate $ Amount
3000 167,843 $2.84 476,674$
3100 Case Management 38,657 $2.21 85,432$
3200 Crisis Services 440 $4.23 1,861$
3300 Medication Support - $4.82 -$
3400 Collateral 10,224 $2.84 29,036$
3500 Plan Development 1,942 $2.84 5,515$
3600 Assessment 38,648 $2.84 109,760$
3700 Rehabilitation 2,536 $2.84 7,202$
260,290 715,480$
Estimated % of Clients that are Medi-Cal Beneficiaries 100%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 715,480$
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00%357,740$
State M/Cal Share of Cost % (BH Realignment/EPSDT) 50.00%357,740$
MEDI-CAL REVENUE TOTAL 715,480$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
5000 Prevention & Early Intervention (PEI) Funds 336,503$
5100 Community Services & Supports (CSS) Funds -$
5200 Innovation (INN) Funds -$
5300 Workforce Education & Training (WET) Funds -$
MHSA FUNDS TOTAL 336,503$
1,051,983$ TOTAL PROGRAM REVENUE
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
NON MEDI-CAL CLIENT SUPPORT TOTAL
MEDI-CAL REVENUE:
Mental Health Services (Individual/Family/Group Therapy)
Estimated Specialty Mental Health Services Billing Totals
OTHER REVENUE:
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
Exhibit B
Page 3 of 15
FTE %Admin Direct Total
0001 FFT Team Site Supervisors 2.00 -$ 203,609$ 203,609$
0002 Clinical Director 0.32 -$ 38,416$ 38,416$
0003 Clinical Oversight/Peer Review 0.30 -$ 43,668$ 43,668$
0004 Community Mental Health Specialists 14.00 -$ 736,276$ 736,276$
0005 Care Managers/Parent Partner 4.00 -$ 164,309$ 164,309$
0006 Finance Dir/HR Mgr/Finance & Clerical Support Varies 43,372$ 70,971$ 114,343$
SALARY TOTAL 43,372$ 1,257,249$ 1,300,621$
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 3,317$ 96,183$ 99,500$
0032 SUI 435$ 11,293$ 11,728$
PAYROLL TAX TOTAL 3,752$ 107,476$ 111,228$
0040 Retirement 2,172$ 62,874$ 65,046$
0041 Workers Compensation 441$ 15,360$ 15,801$
0042 4,780$ 171,998$ 176,778$
EMPLOYEE BENEFITS TOTAL 7,393$ 250,232$ 257,625$
1,669,474$
1010 Rent/Lease Building 120,728$
1011 Rent/Lease Equipment 27,108$
1012 Utilities 27,802$
1013 Building Maintenance 14,567$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 190,205$
FACILITIES/EQUIPMENT EXPENSES:
FUNCTIONAL FAMILY THERAPY SERVICES
COMPREHENSIVE YOUTH SERVICES OF FRESNO, INC.
FY 2019 - 2020
Budget Categories -Total Proposed Budget
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
PAYROLL TAXES:
EMPLOYEE BENEFITS:
Health Insurance (medical, vision, life, dental)
SALARY & BENEFITS GRAND TOTAL
Exhibit B
Page 4 of 15
1060 Telephone 25,994$
1061 Answering Service -$
1062 Postage -$
1063 Printing/Reproduction 300$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 17,408$
1067 Household Supplies -$
1068 Food 1,200$
1069 Program Supplies - Therapeutic 6,000$
1070 Program Supplies - Medical -$
1071 Transportation of Clients -$
1072 Staff Mileage/vehicle maintenance 48,761$
1073 Staff Travel (Out of County)9,440$
1074 Staff Training/Registration 40,066$
1075 Lodging 8,660$
1076 Other - (Identify)-$
1077 Other - (Identify)-$
OPERATING EXPENSES TOTAL 157,829$
1080 Accounting/Bookkeeping -$
1081 External Audit 8,477$
1082 Liability Insurance -$
1083 Administrative Overhead 7,174$
1084 Payroll Services 4,696$
1085 Professional Liability Insurance 9,977$
FINANCIAL SERVICES TOTAL 30,324$
1090 Consultant 19,318$
1091 Translation Services 2,000$
1092 Medication Supports 750$
SPECIAL EXPENSES TOTAL 22,068$
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Leased Automobile 6,300$
FIXED ASSETS TOTAL 6,300$
OPERATING EXPENSES:
FINANCIAL SERVICES EXPENSES:
SPECIAL EXPENSES (Consultant/Etc.):
FIXED ASSETS:
Exhibit B
Page 5 of 15
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)12,000$
2002.2 Client Transportation & Support (SFC 72)3,500$
2002.3 Education Support (SFC 72)3,000$
2002.4 Employment Support (SFC 72)1,500$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
20,000$
TOTAL PROGRAM EXPENSES 2,096,200$
Units of Service Rate $ Amount
3000 333,866 $2.84 948,179$
3100 Case Management 76,890 $2.21 169,927$
3200 Crisis Services 876 $4.23 3,705$
3300 Medication Support - $4.82 -$
3400 Collateral 20,338 $2.84 57,760$
3500 Plan Development 3,863 $2.84 10,971$
3600 Assessment 76,876 $2.84 218,328$
3700 Rehabilitation 5,044 $2.84 14,325$
517,753 1,423,195$
Estimated % of Clients that are Medi-Cal Beneficiaries 100%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 1,423,195$
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00%711,598$
State M/Cal Share of Cost % (BH Realignment/EPSDT) 50.00%711,598$
MEDI-CAL REVENUE TOTAL 1,423,195$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
5000 Prevention & Early Intervention (PEI) Funds 673,005$
5100 Community Services & Supports (CSS) Funds -$
5200 Innovation (INN) Funds -$
5300 W orkforce Education & Training (WET) Funds -$
MHSA FUNDS TOTAL 673,005$
2,096,200$ TOTAL PROGRAM REVENUE
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
NON MEDI-CAL CLIENT SUPPORT TOTAL
MEDI-CAL REVENUE:
Mental Health Services (Individual/Family/Group Therapy)
Estimated Specialty Mental Health Services Billing Totals
OTHER REVENUE:
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
Exhibit B
Page 6 of 15
FTE %Admin Direct Total
0001 FFT Team Site Supervisors 2.00 -$ 210,515$ 210,515$
0002 Clinical Director 0.32 -$ 39,798$ 39,798$
0003 Clinical Oversight/Peer Review 0.30 -$ 45,246$ 45,246$
0004 Community Mental Health Specialists 14.00 -$ 763,897$ 763,897$
0005 Care Managers/Parent Partner 4.00 -$ 169,915$ 169,915$
0006 Finance Dir/HR Mgr/Finance & Clerical Support Varies 44,921$ 73,491$ 118,412$
SALARY TOTAL 44,921$ 1,302,862$ 1,347,783$
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 3,436$ 99,672$ 103,108$
0032 SUI 489$ 12,702$ 13,191$
PAYROLL TAX TOTAL 3,925$ 112,374$ 116,299$
0040 Retirement 2,248$ 65,155$ 67,403$
0041 Workers Compensation 456$ 15,919$ 16,375$
0042 4,942$ 177,811$ 182,753$
EMPLOYEE BENEFITS TOTAL 7,646$ 258,885$ 266,531$
1,730,613$
1010 Rent/Lease Building 123,899$
1011 Rent/Lease Equipment 27,504$
1012 Utilities 28,372$
1013 Building Maintenance 14,120$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 193,895$
FACILITIES/EQUIPMENT EXPENSES:
FUNCTIONAL FAMILY THERAPY SERVICES
COMPREHENSIVE YOUTH SERVICES OF FRESNO, INC.
FY 2020 - 2021
Budget Categories -Total Proposed Budget
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
PAYROLL TAXES:
EMPLOYEE BENEFITS:
Health Insurance (medical, vision, life, dental)
SALARY & BENEFITS GRAND TOTAL
Exhibit B
Page 7 of 15
1060 Telephone 26,267$
1061 Answering Service -$
1062 Postage -$
1063 Printing/Reproduction 300$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 18,130$
1067 Household Supplies -$
1068 Food 1,200$
1069 Program Supplies - Therapeutic 6,000$
1070 Program Supplies - Medical -$
1071 Transportation of Clients -$
1072 Staff Mileage/vehicle maintenance 48,766$
1073 Staff Travel (Out of County)5,565$
1074 Staff Training/Registration 15,593$
1075 Lodging 5,550$
1076 Other - (Identify)-$
1077 Other - (Identify)-$
OPERATING EXPENSES TOTAL 127,371$
1080 Accounting/Bookkeeping -$
1081 External Audit 8,732$
1082 Liability Insurance -$
1083 Administrative Overhead 7,305$
1084 Payroll Services 4,837$
1085 Professional Liability Insurance 10,198$
FINANCIAL SERVICES TOTAL 31,072$
1090 Consultant 19,372$
1091 Translation Services 2,000$
1092 Medication Supports 750$
SPECIAL EXPENSES TOTAL 22,122$
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Leased Automobile 6,300$
FIXED ASSETS TOTAL 6,300$
OPERATING EXPENSES:
FINANCIAL SERVICES EXPENSES:
SPECIAL EXPENSES (Consultant/Etc.):
FIXED ASSETS:
Exhibit B
Page 8 of 15
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)12,000$
2002.2 Client Transportation & Support (SFC 72)3,500$
2002.3 Education Support (SFC 72)3,000$
2002.4 Employment Support (SFC 72)1,500$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
20,000$
TOTAL PROGRAM EXPENSES 2,131,373$
Units of Service Rate $ Amount
3000 342,117 $2.84 971,612$
3100 Case Management 78,790 $2.21 174,126$
3200 Crisis Services 898 $4.23 3,799$
3300 Medication Support - $4.82 -$
3400 Collateral 20,840 $2.84 59,186$
3500 Plan Development 3,958 $2.84 11,241$
3600 Assessment 78,776 $2.84 223,724$
3700 Rehabilitation 5,169 $2.84 14,680$
530,548 1,458,368$
Estimated % of Clients that are Medi-Cal Beneficiaries 100%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 1,458,368$
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00%729,184$
State M/Cal Share of Cost % (BH Realignment/EPSDT) 50.00%729,184$
MEDI-CAL REVENUE TOTAL 1,458,368$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
5000 Prevention & Early Intervention (PEI) Funds 673,005$
5100 Community Services & Supports (CSS) Funds -$
5200 Innovation (INN) Funds -$
5300 W orkforce Education & Training (WET) Funds -$
MHSA FUNDS TOTAL 673,005$
2,131,373$ TOTAL PROGRAM REVENUE
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
NON MEDI-CAL CLIENT SUPPORT TOTAL
MEDI-CAL REVENUE:
Mental Health Services (Individual/Family/Group Therapy)
Estimated Specialty Mental Health Services Billing Totals
OTHER REVENUE:
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
Exhibit B
Page 9 of 15
FTE %Admin Direct Total
0001 FFT Team Site Supervisors 2.00 -$ 214,761$ 214,761$
0002 Clinical Director 0.32 -$ 40,593$ 40,593$
0003 Clinical Oversight/Peer Review 0.30 -$ 46,155$ 46,155$
0004 Community Mental Health Specialists 14.00 -$ 779,224$ 779,224$
0005 Care Managers/Parent Partner 4.00 -$ 173,737$ 173,737$
0006 Finance Dir/HR Mgr/Finance & Clerical Support Varies 45,812$ 75,020$ 120,832$
SALARY TOTAL 45,812$ 1,329,490$ 1,375,302$
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 3,505$ 101,706$ 105,211$
0032 SUI 455$ 11,769$ 12,224$
PAYROLL TAX TOTAL 3,960$ 113,475$ 117,435$
0040 Retirement 2,294$ 66,489$ 68,783$
0041 Workers Compensation 465$ 16,242$ 16,707$
0042 5,166$ 185,893$ 191,059$
EMPLOYEE BENEFITS TOTAL 7,925$ 268,624$ 276,549$
1,769,286$
1010 Rent/Lease Building 127,166$
1011 Rent/Lease Equipment 27,913$
1012 Utilities 28,960$
1013 Building Maintenance 14,421$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 198,460$
FACILITIES/EQUIPMENT EXPENSES:
FUNCTIONAL FAMILY THERAPY SERVICES
COMPREHENSIVE YOUTH SERVICES OF FRESNO, INC.
FY 2021 - 2022
Budget Categories -Total Proposed Budget
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
PAYROLL TAXES:
EMPLOYEE BENEFITS:
Health Insurance (medical, vision, life, dental)
SALARY & BENEFITS GRAND TOTAL
Exhibit B
Page 10 of 15
1060 Telephone 26,547$
1061 Answering Service -$
1062 Postage -$
1063 Printing/Reproduction 300$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 17,825$
1067 Household Supplies -$
1068 Food 1,200$
1069 Program Supplies - Therapeutic 6,000$
1070 Program Supplies - Medical -$
1071 Transportation of Clients -$
1072 Staff Mileage/vehicle maintenance 48,771$
1073 Staff Travel (Out of County)6,690$
1074 Staff Training/Registration 23,770$
1075 Lodging 7,050$
1076 Other - (Identify)-$
1077 Other - (Identify)-$
OPERATING EXPENSES TOTAL 138,153$
1080 Accounting/Bookkeeping -$
1081 External Audit 8,994$
1082 Liability Insurance -$
1083 Administrative Overhead 7,439$
1084 Payroll Services 4,982$
1085 Professional Liability Insurance 10,426$
FINANCIAL SERVICES TOTAL 31,841$
1090 Consultant 19,429$
1091 Translation Services 2,000$
1092 Medication Supports 750$
SPECIAL EXPENSES TOTAL 22,179$
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Leased Automobile 6,300$
FIXED ASSETS TOTAL 6,300$
OPERATING EXPENSES:
FINANCIAL SERVICES EXPENSES:
SPECIAL EXPENSES (Consultant/Etc.):
FIXED ASSETS:
Exhibit B
Page 11 of 15
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)12,000$
2002.2 Client Transportation & Support (SFC 72)3,500$
2002.3 Education Support (SFC 72)3,000$
2002.4 Employment Support (SFC 72)1,500$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
20,000$
TOTAL PROGRAM EXPENSES 2,186,219$
Units of Service Rate $ Amount
3000 354,985 $2.84 1,008,157$
3100 Case Management 81,754 $2.21 180,676$
3200 Crisis Services 931 $4.23 3,938$
3300 Medication Support - $4.82 -$
3400 Collateral 21,624 $2.84 61,412$
3500 Plan Development 4,107 $2.84 11,664$
3600 Assessment 81,738 $2.84 232,136$
3700 Rehabilitation 5,363 $2.84 15,231$
550,502 1,513,214$
Estimated % of Clients that are Medi-Cal Beneficiaries 100%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 1,513,214$
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00%756,607$
State M/Cal Share of Cost % (BH Realignment/EPSDT) 50.00%756,607$
MEDI-CAL REVENUE TOTAL 1,513,214$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
5000 Prevention & Early Intervention (PEI) Funds 673,005$
5100 Community Services & Supports (CSS) Funds -$
5200 Innovation (INN) Funds -$
5300 W orkforce Education & Training (WET) Funds -$
MHSA FUNDS TOTAL 673,005$
2,186,219$ TOTAL PROGRAM REVENUE
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
NON MEDI-CAL CLIENT SUPPORT TOTAL
MEDI-CAL REVENUE:
Mental Health Services (Individual/Family/Group Therapy)
Estimated Specialty Mental Health Services Billing Totals
OTHER REVENUE:
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
Exhibit B
Page 12 of 15
FTE %Admin Direct Total
0001 FFT Team Site Supervisors 2.00 -$ 221,686$ 221,686$
0002 Clinical Director 0.32 -$ 41,658$ 41,658$
0003 Clinical Oversight/Peer Review 0.30 -$ 47,538$ 47,538$
0004 Community Mental Health Specialists 14.00 -$ 802,798$ 802,798$
0005 Care Managers/Parent Partner 4.00 -$ 178,985$ 178,985$
0006 Finance Dir/HR Mgr/Finance & Clerical Support Varies 47,162$ 77,269$ 124,431$
SALARY TOTAL 47,162$ 1,369,934$ 1,417,096$
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 3,608$ 104,799$ 108,407$
0032 SUI 509$ 13,179$ 13,688$
PAYROLL TAX TOTAL 4,117$ 117,978$ 122,095$
0040 Retirement 2,361$ 68,509$ 70,870$
0041 Workers Compensation 479$ 16,739$ 17,218$
0042 5,345$ 192,357$ 197,702$
EMPLOYEE BENEFITS TOTAL 8,185$ 277,605$ 285,790$
1,824,981$
1010 Rent/Lease Building 130,531$
1011 Rent/Lease Equipment 28,334$
1012 Utilities 29,565$
1013 Building Maintenance 15,433$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 203,863$
FACILITIES/EQUIPMENT EXPENSES:
FUNCTIONAL FAMILY THERAPY SERVICES
COMPREHENSIVE YOUTH SERVICES OF FRESNO, INC.
FY 2022 - 2023
Budget Categories -Total Proposed Budget
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
PAYROLL TAXES:
EMPLOYEE BENEFITS:
Health Insurance (medical, vision, life, dental)
SALARY & BENEFITS GRAND TOTAL
Exhibit B
Page 13 of 15
1060 Telephone 26,837$
1061 Answering Service -$
1062 Postage -$
1063 Printing/Reproduction 300$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 18,026$
1067 Household Supplies -$
1068 Food 1,200$
1069 Program Supplies - Therapeutic 6,000$
1070 Program Supplies - Medical -$
1071 Transportation of Clients -$
1072 Staff Mileage/vehicle maintenance 48,776$
1073 Staff Travel (Out of County)4,015$
1074 Staff Training/Registration 12,648$
1075 Lodging 4,350$
1076 Other - (Identify)-$
1077 Other - (Identify)-$
OPERATING EXPENSES TOTAL 122,152$
1080 Accounting/Bookkeeping -$
1081 External Audit 9,264$
1082 Liability Insurance -$
1083 Administrative Overhead 7,579$
1084 Payroll Services 5,132$
1085 Professional Liability Insurance 10,661$
FINANCIAL SERVICES TOTAL 32,636$
1090 Consultant 19,486$
1091 Translation Services 2,000$
1092 Medication Supports 750$
SPECIAL EXPENSES TOTAL 22,236$
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Leased Automobile 6,300$
FIXED ASSETS TOTAL 6,300$
OPERATING EXPENSES:
FINANCIAL SERVICES EXPENSES:
SPECIAL EXPENSES (Consultant/Etc.):
FIXED ASSETS:
Exhibit B
Page 14 of 15
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)12,000$
2002.2 Client Transportation & Support (SFC 72)3,500$
2002.3 Education Support (SFC 72)3,000$
2002.4 Employment Support (SFC 72)1,500$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
20,000$
TOTAL PROGRAM EXPENSES 2,232,168$
Units of Service Rate $ Amount
3000 365,762 $2.84 1,038,764$
3100 Case Management 84,236 $2.21 186,162$
3200 Crisis Services 960 $4.23 4,061$
3300 Medication Support - $4.82 -$
3400 Collateral 22,281 $2.84 63,278$
3500 Plan Development 4,232 $2.84 12,019$
3600 Assessment 84,220 $2.84 239,185$
3700 Rehabilitation 5,526 $2.84 15,694$
567,217 1,559,163$
Estimated % of Clients that are Medi-Cal Beneficiaries 100%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 1,559,163$
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00%779,582$
State M/Cal Share of Cost % (BH Realignment/EPSDT) 50.00%779,582$
MEDI-CAL REVENUE TOTAL 1,559,163$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
5000 Prevention & Early Intervention (PEI) Funds 673,005$
5100 Community Services & Supports (CSS) Funds -$
5200 Innovation (INN) Funds -$
5300 W orkforce Education & Training (WET) Funds -$
MHSA FUNDS TOTAL 673,005$
2,232,168$ TOTAL PROGRAM REVENUE
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
NON MEDI-CAL CLIENT SUPPORT TOTAL
MEDI-CAL REVENUE:
Mental Health Services (Individual/Family/Group Therapy)
Estimated Specialty Mental Health Services Billing Totals
OTHER REVENUE:
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
Exhibit B
Page 15 of 15
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
rev 01-02-2018
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
•Deliver quality care
•Maximize resources while focusing on efficiency
•Provide an excellent care experience
•Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit C
Page 1 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
rev 01-02-2018
2.Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3.Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4.Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5.Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit C
Page 2 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
rev 01-02-2018
6.Principle Six - Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7.Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8.Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9.Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit C
Page 3 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
rev 01-02-2018
10.Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11.Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit C
Page 4 of 4
Exhibit D
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1.Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2.Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3.Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4.NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5.Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6.Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7.Bill only for eligible services actually rendered and fully documented. Use billing codes that
Exhibit D
Page 2 of 3
accurately describe the services provided.
8.Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9.Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11.Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit D
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
Exhibit E
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics.
A.Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
•Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
•Presenting problems and relevant conditions affecting the client’s physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
•Documentation will describe client’s strengths in achieving client plan goals.
•Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
•Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
•Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
•A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
•For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
•Documentations will include past and present use of tobacco, alcohol, and caffeine, as
well as illicit, prescribed and over-the-counter drugs.
•A relevant mental status examination will be documented.
•A five axis diagnosis from the most current DSM, or a diagnosis from the most current
ICD, will be documented, consistent with the presenting problems, history mental status
evaluation and/or other assessment data.
2.Timeliness/Frequency Standard for Assessment
•An assessment will be completed at intake and updated as needed to document changes in
the client’s condition.
•Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B.Client Plans
1.Client plans will:
Exhibit E
Page 2 of 3
•have specific observable and/or specific quantifiable goals
•identify the proposed type(s) of intervention
•have a proposed duration of intervention(s)
•be signed (or electronic equivalent) by:
the person providing the service(s), or
a person representing a team or program providing services, or
a person representing the MHP providing services
when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
a physician
a licensed/ “waivered” psychologist
a licensed/ “associate” social worker
a licensed/ registered/marriage and family therapist or
a registered nurse
•In addition,
client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client’s
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to, reference to the client’s participation and agreement in the body
of the plan, client signature on the plan, or a description of the client’s participation
and agreement in progress notes.
client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
when the client’s signature is required on the client plan and the client refuses or is
unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
•The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2.Timeliness/Frequency of Client Plan:
•Will be updated at least annually
•The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C.Progress Notes
1.Items that must be contained in the client record related to the client’s progress in treatment
include:
•The client record will provide timely documentation of relevant aspects of client care
•Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
•All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person’s professional degree, licensure or job title;
and the relevant identification number, if applicable
Exhibit E
Page 3 of 3
•All entries will include the date services were provided
•The record will be legible
•The client record will document follow-up care, or as appropriate, a discharge summary
2.Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A.Every Service Contact
•Mental Health Services
•Medication Support Services
•Crisis Intervention
Exhibit F
Page 1 of 2
STATE MENTAL HEALTH REQUIREMENTS
1.CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2.PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3.CONFIDENTIALITY
CONTRACTOR(S) shall conform to and COUNTY shall monitor compliance
with all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4.NON-DISCRIMINATION
A.Eligibility for Services
CONTRACTOR(S) shall prepare and make available to COUNTY and to
the public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B.Employment Opportunity
CONTRACTOR(S) shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit F
Page 2 of 2
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C.Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR(S) can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D.Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR(S)
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR(S).
5.PATIENTS' RIGHTS
CONTRACTOR(S) shall comply with applicable laws and regulations, including
but not limited to, laws, regulations, and State policies relating to patients' rights.
Department of Behavioral Health
Dawan Utecht, Mental Health Director/Public Guardian
Providing Quality Mental Health and Substance Abuse Services for the People of Fresno County
4441 E. Kings Canyon Road / Fresno, California 93702-3604
(559) 600-9180 FAX (559) 600-7674
Equal Employment Opportunity Affirmative Action Disabled Employer
www.co.fresno.ca.us www.fresno.networkofcare.org
Information Notice
Date: May 29, 2018
To: Fresno County Mental Health Plan and Substance Use Services Contracted Providers
Subject: New Policy and Procedure Guide Regarding Incident Reporting and Intensive Analysis
PPG 1.2.4.
Effective June 1st, 2018, all contracted providers working within the Fresno County Mental Health
Plan and Substance Use Disorder Services Providers will need to follow the new instructions for
reporting incidents.
An “Incident” is any event that compromises the health and safety of clients, employees, or community
members. Any employee having knowledge of an incident will need to follow the appropriate reporting
process. Incident reports help to increase safety in the provision of behavioral health care and substance use
disorder services as well as recommend possible system, policy and/or protocol changes.
The list below includes types of incidents to report:
•All client deaths (natural causes or unexplained/unknown reasons)
•Attempted suicide (resulting in serious injury)
•Homicide or attempts at homicide
•Injury connected to services or at a service site (self-inflicted or by accident)
Example- a client trips and falls but doesn’t require medical attention
•Medical Emergency connected to services or at a service site
Example: Client has a seizure/heart attack during appointment
•Other (i.e. Clients escaping from a locked facility, medication erroneously given during
appointment or mistakenly prescribed)
•Violence, Abuse or Assault connected to services or at a service site (toward client, others or
property; resulting in serious injury)
Example: Client hits a staff member/another client, sets fire to a trash can in the building
Reporting Process
1.) The encrypted report shall be completed and signed by the employee involved in or first aware of
an incident.
2.) Reviewed and signed by a supervisor and/or Program Director and sent encrypted to the
designated Contract Staff Analyst and DBHIncidentReporting@co.fresno.ca.us
3.) ***MHRC’s and PHF’s must ALSO send the encrypted 24-Hour Unusual
Occurrence Report (UOR) to the designated reporting contact at DHCS, your Contract Staff
Analyst and DBHIncidentReporting@co.fresno.ca.us within 24 hours of an incident or first
knowledge of an incident.
Steps 1, 2 and 3 must be completed within 24 hours of an incident or first knowledge of an incident.
Exhibit G
Page 1 of 3
All reported incidents are reviewed by the DBH Intensive Analysis Committee (IAC). If further information
is needed, your analyst will contact you as soon as possible. If a reported incident is determined to be an
Unusual Occurrence (which the Department of Health Care Services defines as: any event which jeopardizes
the health and/or safety of clients, staff, and/or members of the community including but not limited to
physical injury and death), Contracted Providers not licensed directly by the state, may elect to submit their
own Unusual Occurrence Report (UOR) in lieu of a DBH Manager or Intensive Analysis Committee
member. UOR’s shall be emailed encrypted to the DHCS designated reporting contact (per DHCS
instructions), your Contract Staff Analyst and DBHIncidentReporting@co.fresno.ca.us within five (5)
calendar days of an incident or first knowledge of an incident.
UOR’s sent to DHCS may be subject to further investigation and/or information requested by DHCS, such
as: Site Reviews and Plan(s) of Correction. A courtesy copy of correspondence between contracted providers
and DHCS regarding UOR’s shall also be sent to your Contract Staff Analyst and
DBHIncidentReporting@co.fresno.ca.us for informational purposes. DBH may also conduct site visits,
request contracted providers attest that an Intensive Analysis or similar (incident review, root cause analysis)
has occurred, and/or may request additional analysis or information when necessary.
If you are not sure if something is considered a reportable incident, need clarification on the reporting
process and/or need a copy of the reporting form(s), contact your Contract Staff Analyst for
assistance.
Exhibit G
Page 2 of 3
Fresno County Department of Behavioral Health-Incident Report
Send completed forms to dbhincidentreporting@co.fresno.ca.us and designated contract analyst within 24 hours of an
incident or knowledge of an incident. DO NOT COPY OR REPRODUCE/NOT part of the medical record.
Client Information
Last Name: Click or tap here to enter text. First Name: Click or tap here to enter text. Middle Initial: Click or tap here to enter text.
Date of Birth:Click or tap here to enter text. Client ID#:Click or tap here to enter text. Gender: ☐ Male ☐ Female
County of Origin: Click or tap here to enter text.
Name of Reporting Party:Click or tap here to enter text. Name of Facility:Click or tap here to enter text.
Facility Address:Click or tap here to enter text. Facility Phone Number:Click or tap here to enter text.
Incident (check all that apply)
☐Homicide/Homicide Attempt ☐ Attempted Suicide (resulting in serious injury) ☐ Death of Client ☐ Medical Emergency
☐Injury (self-inflicted or by accident)☐Violence/Abuse/Attempts to Assault (toward others, client and/or property)
☐Other- Specify (i.e. medication errors, client escaping from locked facility, fire, poisoning, epidemic outbreaks, other
catastrophes/events that jeopardize the welfare and safety of clients, staff and /or members of the community): Click or tap here to
enter text.
Date of Incident: Click or tap here to enter text. Time of Incident: Click or tap here to enter text.☐am ☐pm
Location of Incident: Click or tap here to enter text.
Description of the Incident (Attach additional sheet if needed): Click or tap here to enter text.
Key People Directly Involved in Incident (witnesses, staff): Click or tap here to enter text.
Action Taken (check all that apply) ☐Consulted with Physician ☐ Called 911/EMS ☐ First Aid/CPR Administered ☐Law Enforcement Contacted☐Client removed from building ☐ Parent/Legal Guardian Contacted ☐Other (Specify): Click or tap here to enter text.
Description of Action Taken: Click or tap here to enter text.
Outcome of Incident (If Known): Click or tap here to enter text.
Form Completed by: __________________________________ _______________________________ _____________
Printed Name Signature Date
Reviewed by Supervisor/Program Manager: _____________________________ ___________________________ ________
Printed Name Signature Date
For Internal Use only:
☐Report to Administration ☐ Report to Intensive Analysis Committee for additional review ☐Request Additional Information
☐No Action ☐ Unusual Occurrence ☐ Other: Click or tap here to enter text.
Revised 12 /2017
Exhibit G
Page 3 of 3
Exhibit H
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6.The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8.The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A.All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B.Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C.All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
Exhibit H
Page 2 of 2
D.Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E.Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F.A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G.Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation, the
provider must have a written description of the day treatment intensive and/or day treatment
rehabilitation program that complies with State Department of Health Care Service’s day
treatment requirements. The COUNTY shall review the provider’s written program
description for compliance with the State Department of Health Care Service’s day
treatment requirements.
12. The COUNTY may accept the host county’s site certification and reserves the right to
conduct an on-site certification review at least every three (3) years. The COUNTY may
also conduct additional certification reviews when:
•The provider makes major staffing changes.
•The provider makes organizational and/or corporate structure changes (example:
conversion from a non-profit status).
•The provider adds day treatment or medication support services when medications shall
be administered or dispensed from the provider site.
•There are significant changes in the physical plant of the provider site (some physical
plant changes could require a new fire clearance).
•There is change of ownership or location.
•There are complaints against the provider.
•There are unusual events, accidents, or injuries requiring medical treatment for clients,
staff or members of the community.
Exhibit I
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
•How to access specialty mental health services
•How to file a grievance about services
•How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit I
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process – the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider’s claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care
disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1.Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse
cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Governance, Leadership, and Workforce:
2.Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,
practices, and allocated resources.
3.Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are
responsive to the population in the service area.
4.Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and
practices on an ongoing basis.
Communication and Language Assistance:
5.Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at
no cost to them, to facilitate timely access to all health care and services.
6.Inform all individuals of the availability of language assistance services clearly and in their preferred language,
verbally and in writing.
7.Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals
and/or minors as interpreters should be avoided.
8.Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the
populations in the service area.
Engagement, Continuous Improvement, and Accountability:
9.Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them
throughout the organization’s planning and operations.
10.Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into
measurement and continuous quality improvement activities.
11.Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health
equity and outcomes and to inform service delivery.
12.Conduct regular assessments of community health assets and needs and use the results to plan and implement
services that respond to the cultural and linguistic diversity of populations in the service area.
13.Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural
and linguistic appropriateness.
14.Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent,
and resolve conflicts or complaints.
15.Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and
the general public.
Exhibit J
Page 1 of 2
The Case for the Enhanced National CLAS Standards
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
— Dr. Martin Luther King, Jr.
Health equity is the attainment of the highest level of health for all people (U.S. Department of Health and Human
Services [HHS] Office of Minority Health, 2011). Currently, individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of
health, or those conditions in which individuals are born, grow, live, work, and age (World Health Organization, 2012),
such as socioeconomic status, education level, and the availability of health services (HHS Office of Disease Prevention
and Health Promotion, 2010). Though health inequities are directly related to the existence of historical and current
discrimination and social injustice, one of the most modifiable factors is the lack of culturally and linguistically appropriate
services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of
all individuals.
Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely
affect neighborhoods, communities, and the broader society, thus making the issue not only an individual concern but
also a public health concern. In the United States, it has been estimated that the combined cost of health disparities and
subsequent deaths due to inadequate and/or inequitable care is $1.24 trillion (LaVeist, Gaskin, & Richard, 2009).
Culturally and linguistically appropriate services are increasingly recognized as effective in improving the quality of care
and services (Beach et al., 2004; Goode, Dunne, & Bronheim, 2006). By providing a structure to implement culturally and
linguistically appropriate services, the enhanced National CLAS Standards will improve an organization’s ability to address
health care disparities.
The enhanced National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities
(HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity (HHS National Partnership for Action to
End Health Disparities, 2011), which aim to promote health equity through providing clear plans and strategies to guide
collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives, the
enhanced National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care
disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and
linguistically appropriate services. Adoption of these Standards will help advance better health and health care in the
United States.
Bibliography:
Beach, M. C., Cooper, L. A., Robinson, K. A., Price, E. G., Gary, T. L., Jenckes, M. W., Powe, N.R. (2004). Strategies for improving minority healthcare quality. (AHRQ
Publication No. 04-E008-02). Retrieved from the Agency of Healthcare Research and Quality website:
http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf
Goode, T. D., Dunne, M. C., & Bronheim, S. M. (2006). The evidence base for cultural and linguistic competency in health care. (Commonwealth Fund Publication No. 962).
Retrieved from The Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf
LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Retrieved from the Joint Center for Political and Economic
Studies website: http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2
0Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf
National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for achieving health equity. Retrieved from U.S. Department of Health and
Human Services, Office of Minority Health website: http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care.
Retrieved from http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy people 2020: Social determinants of health. Retrieved
from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39
U.S. Department of Health and Human Services, Office of Minority Health (2011). National Partnership for Action to End Health Disparities. Retrieved from
http://minorityhealth.hhs.gov/npa
World Health Organization. (2012). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/
Exhibit J
Page 2 of 2
Exhibit K
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 K
Page 2 0f 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V.Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI.Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B.If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit L
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1.By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2.The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3.The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4.The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5.The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6.Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit L
Page 2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a)Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b)Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c)Have not within a three-year period preceding this application/proposal had
one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or Company)
Exhibit M
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 M
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: