HomeMy WebLinkAboutAgreement A-19-173 with Hinds Hospice.pdf1
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Agreement No . 19-173
AGREEMENT
This Agreement is made and entered into this 9th day of April 2019 , by and
between the COUNTY OF FRESNO, a Political Subdivision of the State of California , hereinafter referred
to as "COUNTY", and Hinds Hospice, a California non-profit corporation , whose address is 2490 W .
Shaw Avenue, Fresno , CA 93711, 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 committed to raising
awareness, providing education and training on suicide prevention , and reducing stigma ; and
WHEREAS , COUNTY , through its DBH , Mental Health Services Act (MHSA) Prevention and Early
Intervention (PEI) component, and through input from the Fresno County Suicide Prevention
Collaborative and community stakeholder process, recognizes the need of a qualified agency to operate a
Local Outreach to Suicide Survivors (LOSS) Team in Fresno County to help provide immediate
assistance to suicide survivors to help them cope with the trauma of their loss, provide follow-up contact
with the survivors , and coordinate the utilization of services and support groups within the community ; and
WHEREAS , COUNTY, through its 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 uniquely qualified , willing and able to provide services required by
the COUNTY , pursuant to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto
agree as follows :
1. SERVICES
A . CONTRACTOR shall perform all services and fulfill all responsibilities set for in
Exhibit A "Summary of Services", which is attached hereto and by this reference incorporated herein and
made part of this Agreement.
B . CONTRACTOR shall align programs, services , and practices with the vision ,
mission, and guiding principles of the DBH , as further described in Exhibit B , "Fresno County Department
of Behavioral Health Guiding Principles of Care Delivery", attached hereto and by this reference
incorporated herein and made part of this Agreement.
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C 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.
D.CONTRACTOR shall participate in periodic 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.
E.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.
F.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
The Agreement shall become effective upon execution and shall terminate on the 30th of
June, 2022. This agreement may be extended for two (2) additional consecutive twelve (12) month
periods upon the approval of both parties no later than thirty (30) days prior to the first day of the next
twelve (12) month extension period. The DBH Director, or 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 sixty (60) 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;
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3)A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any
breach of this Agreement or any default which may then exist on the part of CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or
default. COUNTY shall have the right to demand of CONTRACTOR the repayment to COUNTY of any
funds disbursed to CONTRACTOR under this Agreement, which in the judgment of COUNTY were not
expended in accordance with the terms of this Agreement. 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 sixty (60) days advance written
notice of an intention to terminate the Agreement. COUNTY’s DBH Director, or designee, is authorized to
execute such written notice on behalf of COUNTY
4.COMPENSATION
For actual services provided as identified in the terms and conditions of this Agreement,
including Exhibit A, COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with Exhibit C, “Budget Summary,” attached hereto and by this reference
incorporated herein. Mandated travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the IRS published rate.
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.
The maximum amount payable to CONTRACTOR for the ramp up period (effective upon
execution through June 30, 2019), shall not exceed Eighty-Five Thousand, Four Hundred Eighty-Five and
No/100 Dollars ($85,485.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2019 through
June 30, 2020 shall not exceed Three Hundred Thirty-Seven Thousand, Seven Hundred Seventy-Seven
and No/100 Dollars ($337,777.00).
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The maximum amount payable to CONTRACTOR for the period of July 1, 2020 through
June 30, 2021 shall not exceed Three Hundred Forty-Six Thousand, Six Hundred Thirty-One and No/100
Dollars ($346,631.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2021 through
June 30, 2022 shall not exceed Three Hundred Fifty-One Thousand, Eight Hundred Sixty and No/100
Dollars ($351,860.00).
If this Agreement is extended for an additional twelve (12) month renewal period beginning
July 1, 2022 through June 30, 2023, the maximum amount payable to CONTRACTOR for said period
shall not exceed Three Hundred Fifty-Five Thousand, Four Hundred Eighty-Nine and No/100 Dollars
($355,489.00).
If this Agreement is extended for an additional twelve (12) month renewal period beginning
July 1, 2023 through June 30, 2024, the maximum amount payable to CONTRACTOR for said period
shall not exceed Three Hundred Sixty Thousand, Six Hundred Twenty-Two and No/100 Dollars
($360,622.00).
The cumulative total of this Agreement shall not be in excess of One Million, Eight Hundred
Thirty-Seven Thousand, Eight Hundred Sixty-Four and No/100 Dollars ($1,837,864.00). It is understood
that all expenses incidental to CONTRACTOR’s performance of services under this Agreement shall be
borne by CONTRACTOR.
Except as provided below regarding State payment delays, 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, verification, and approval of CONTRACTOR’s invoices by COUNTY’s
DBH. The parties acknowledge that the CONTRACTOR will be performing hiring, training, and
credentialing of staff, and the COUNTY will be performing additional staff credentialing to ensure
compliance with State and Federal regulations.
If CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY
shall be relieved of its obligation for further compensation. 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 claims submitted beyond the sixty (60) day closeout period. Any
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compensation which is not expended by CONTRACTOR pursuant to the terms and conditions of this
Agreement shall automatically revert to COUNTY.
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 payment to CONTRACTOR. The amount of the deferred payment shall
not exceed the amount of funding delayed by the State Controller to COUNTY. The period of time of the
deferral by COUNTY shall not exceed the period of time of the State Controller’s delay of payment to
COUNTY plus forty-five (45) days.
CONTRACTOR shall be held financially liable for any and all future disallowances/audit
exceptions due to CONTRACTOR’s deficiency discovered through the State audit process and COUNTY
utilization review during the course of this Agreement. At COUNTY’s election, the disallowed amount will
be remitted within forty-five (45) days to COUNTY upon notification or shall be withheld from subsequent
payments to CONTRACTOR. CONTRACTOR shall not receive reimbursement for any units of services
rendered that are disallowed or denied by the Fresno County Mental Health Plan (Mental Health Plan)
utilization review process or through the State Department of Health Care Services (DHCS) cost report
audit settlement process for Medi-Cal eligible clients. Notwithstanding the above, COUNTY must notify
CONTRACTOR prior to any State audit process and/or COUNTY utilization review. To the extent
allowable by law, CONTRACTOR shall have the right to be present during each phase of any State audit
process and/or COUNTY utilization review and shall be provided all documentation related to each phase
of any State audit process and/or COUNTY utilization review. Additionally, prior to any
disallowances/audit exceptions becoming final, CONTRACTOR shall be given at least ten (10) business
days to respond to such proposed disallowances/audit exceptions.
5.INVOICING
CONTRACTOR shall invoice COUNTY in arrears by the twentieth (20th) day of each
month for actual expenses incurred and services rendered in the previous month to:
DBH-Invoices@fresnocountyca.gov. A Monthly Activity Report shall accompany the invoice, reflecting
services supported by the invoiced expenditures and be in a form and in such detail as acceptable to
COUNTY’s DBH.
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CONTRACTOR shall submit to the COUNTY by the twentieth (20th) of each month a
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. Supporting documentation shall
include but is not limited to receipts, invoices received, and documented administrative / overhead costs.
No reimbursement for services shall be made until invoices, reports and outcomes are received, reviewed
and approved by COUNTY’s DBH.
CONTRACTOR shall submit monthly staffing reports that identify all direct service and
support staff, applicable licensure/certifications, ethnicity and language detail of staff, and actual time of
hours (FTE) worked to be used as a tracking tool to determine if CONTRACTOR’s program is staffed
according to the services provided under this Agreement. Monthly staffing reports shall indicate if staff
licenses are valid and current.
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’s DBH satisfaction, COUNTY’s DBH Director or designee may
elect to terminate this Agreement, pursuant to the termination provisions stated in Paragraph 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.
CONTRACTOR must maintain such 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.
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
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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.
7.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent of
all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to services, staffing, and responsibilities of the
CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health treatment, as
set forth in Exhibit A, may be made with the signed written approval of COUNTY’s DBH Director, or his or
her 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, and
changes to the volume of units of services/types of service units to be provided as set forth in Exhibit C
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that do not exceed ten percent (10%) of the maximum compensation payable to the CONTRACTOR may
be made with the written approval of COUNTY’s DBH Director, or his or her designee. Changes to the
expense categories in the budget that exceed ten percent (10%) of the maximum compensation payable
to the CONTRACTOR, may be made with the signed written approval of COUNTY’s DBH Director, or his
or her designee through an amendment approved by COUNTY’s Counsel and COUNTY’s Auditor-
Controller’s Office.
Said modifications shall not result in any change to the annual maximum compensation
amount payable to CONTRACTOR, as stated in this Agreement.
CONTRACTOR hereby agrees that changes to the compensation under this Agreement
may be necessitated by a reduction in funding from State and / or Federal sources. COUNTY’s DBH
Director or designee may modify the maximum compensation depending on State and Federal funding
availability, as stated in Section Four (4) in this Agreement. CONTRACTOR further understands that this
Agreement is subject to any restrictions, limitations or enactments of all legislative bodies which affect the
provisions, term, or funding of this Agreement in any manner.
8.NON-ASSIGNMENT
Neither party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of the other party.
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 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 performance, or failure to perform, of
CONTRACTOR, its officers, agents, or employees under this Agreement. In addition, CONTRACTOR
agrees to indemnify COUNTY for Federal, State of California and / or local audit exceptions resulting from
noncompliance herein on the part of the CONTRACTOR.
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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 effect the following insurance
policies throughout the term of this Agreement:
A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Three Million
Dollars ($3,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverages including completed operations, product
liability, contractual liability, Explosion-Collapse-Underground, fire legal liability or
any other liability insurance deemed necessary because of the nature of the
Agreement.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits no less than One Million
Dollars ($1,000,000) per accident for bodily injury and property damage. Coverage
should include any automobile used in connection with this Agreement. If
CONTRACTOR’s employees are not covered by CONTRACTOR’s automobile
liability insurance policy, CONTRACTOR shall ensure that each employee as part
of this Agreement procures and maintains their own private automobile coverage in
force during the term of this Agreement, at the employee’s sole cost and expense.
C.Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N., L.C.S.W.,
L.M.F.T., etc.) in providing services, Professional Liability Insurance with limits of
not less than One Million Dollars ($1,000,000) per occurrence, Three Million Dollars
($3,000,000) annual aggregate. CONTRACTOR agrees that it shall maintain, at its
sole expense, in full force and effect for a period of five (5) years following the
termination of this Agreement, one or more policies of professional liability
insurance with limits of coverage as specified herein.
D.Real and Property Insurance
CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
loss payee. The personal property coverage shall be in an amount that will cover
the total of the COUNTY purchase and owned property, at a minimum, as
discussed in Section Twenty (20) of this Agreement.
E.All Risk Property Insurance
As applicable, CONTRACTOR will provide property coverage for the full
replacement value of the COUNTY’S personal property in possession of
CONTRACTOR and/or used in the execution of this Agreement. COUNTY will be
identified on an appropriate certificate of insurance as the certificate holder and will
be named as an Additional Loss Payee on the Property Insurance Policy.
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F.W orker’s Compensation
A policy of Worker's Compensation Insurance as may be required by the California
Labor Code.
G.Child Abuse/Molestation and Social Services Coverage
Each CONTRACTOR shall have either separate policies or an umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability. The policy
limits for these policies shall be One Million Dollars ($1,000,000) per occurrence
with a Two Million Dollars ($2,000,000) annual aggregate. The policies are to be on
a per occurrence basis.
H.Cyber Liability
Cyber Liability Insurance, with limits not less than One Million Dollars ($1,000,000)
per occurrence or claim, One Million Dollars ($1,000,000) aggregate. Coverage
shall be sufficiently broad to respond to the duties and obligations as is 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.
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents and employees shall be excess only and not
contributing with insurance provided under CONTRACTOR’s policies herein. This insurance shall not be
cancelled or changed without a minimum of thirty (30) days advance written notice given to COUNTY.
CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and
employees any amounts paid by the policy of worker’s compensation insurance required by this
Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be
necessary to accomplish such waiver of subrogation, but CONTRACTOR’s waiver of subrogation under
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this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
Within thirty (30) days from the date each CONTRACTOR signs this Agreement, said
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, Public
Behavioral Health Division, 2085 E. Dakota Ave, Fresno, California, 93726, Attention: LOSS Team
Contract Staff Analyst, stating that such insurance coverages have been obtained and are in full force;
that the County of Fresno, its officers, agents and employees will not be responsible for any premiums on
the policies; that for such worker’s compensation insurance the CONTRACTOR has waived its right to
recover from the COUNTY, its officers, agents, and employees any amounts paid under the insurance
policy and that waiver does not invalidate the insurance policy; 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 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. CONTRACTOR shall
provide COUNTY DBH, monthly staffing reports indicating staff licenses are valid and current.
12.RECORDS
COUNTY shall be allowed to review all records of services provided, including the goals
and objectives of the service plans, and how the services provided is achieving the goals and objectives.
All records shall be maintained for a minimum of ten (10) years from the date of the end of the
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 performance outcome measures
requirements are subject to change at COUNTY’s DBH discretion. Outcome reports are further
referenced in Exhibit A and Exhibit D, “Performance Outcome Measures”, attached hereto and
incorporated herein by reference and made part of this Agreement.
B.Additional Reports
CONTRACTOR shall submit to COUNTY's DBH by the twentieth (20th) of each
month all monthly activity and budget reports for the preceding month. 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.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and the
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State DHCS, or their designees, the right to review and monitor records, services or procedures, at any
time, in regard to clients, as well as the overall operation of CONTRACTOR’s performance, in order to
ensure compliance with the terms and conditions of this Agreement.
15.REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended during
the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of
such amendment.
16.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State DHCS, and that under said agreement the State imposes certain requirements
on COUNTY and its subcontractors. CONTRACTOR shall adhere to all State requirements, including
those identified in Exhibit E, “State Mental Health Requirements”, attached hereto and by this reference
incorporated herein and made part of this Agreement. CONTRACTOR shall also file an incident report
for all incidents involving clients, following the COUNTY’s DBH’s “Incident Reporting and Intensive
Analysis” policy and procedure guide and using the “Incident Report” Worksheet identified in Exhibit F,
“Fresno County Mental Health Plan 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 his or her designee.
17.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.
18.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
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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 (CFR).
19.DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into
a contractual relationship with the COUNTY for the purpose of providing services under this Agreement
must employ adequate data security measures to protect the confidential information provided to
CONTRACTOR by the COUNTY, including but not limited to the following:
A.CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1)CONTRACTOR has received authorization by COUNTY for
telecommuting purposes;
2)Current virus protection software is in place;
3)Mobile device has the remote wipe feature enabled; and
4)A secure connection is used.
B.CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief Information
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Officer, and/or his or her designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on non-
COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer, and/or his or
her designee(s).
D.CONTRACTOR may not store COUNTY’s private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E.CONTRACTOR shall be responsible to employ strict controls to ensure the integrity
and security of COUNTY’s confidential information and to prevent unauthorized access, viewing, use or
disclosure of data maintained in computer files, program documentation, data processing systems, data
files and data processing equipment which stores or processes COUNTY data internally and externally.
F.Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
BIT or higher. Additionally, a password or pass phrase must be utilized.
G.CONTRACTOR is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data maintained
in computer files, program documentation, data processing systems, data files and data processing
equipment which stores or processes COUNTY data internally or externally.
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.
20.PROPERTY OF COUNTY
A.COUNTY and CONTRACTOR recognizes that fixed assets are tangible and
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intangible property obtained or controlled under COUNTY’s MHP for use in operational capacity and will
benefit COUNTY for a period more than one year. Depreciation of the qualified items will be on a
straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1.Asset must have life span of over one year.
2.The asset is not a repair part.
3.The asset must be valued at or greater than the capitalization thresholds for
the asset type.
Asset Type Threshold
•Land $ 0
•Building and Improvements $ 100,000
•Infrastructure $ 100,000
•Tangible $ 5,000
o Equipment
o Vehicles
•Intangible Asset $ 100,000
o Internal Generate 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”, attached hereto as Exhibit G and by this reference incorporated herein and made part of this
Agreement, will be maintained by COUNTY’s Asset Management System and annual inventoried until the
asset is fully depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be
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 (1) year life span, and/or are mobile and high risk of theft or loss are
sensitive assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and
other sensitive items as determined by COUNTY’s DBH Director, or his or her designee. CONTRACTOR
maintains a tracking system on the items and are not required to be capitalize or depreciated. The items
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are subject to annual inventory for compliance.
C.Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in
an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of this
Agreement, CONTRACTOR shall be physically present when fixed and inventoried assets are returned to
COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY owned
undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1.To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2.To label all items of equipment with COUNTY assigned program number, to
perform periodic inventories as required by COUNTY and to maintain an inventory list showing where and
how the equipment is being used, in accordance with procedures developed by COUNTY. All such lists
shall be submitted to COUNTY within ten (10) days of any request therefore; and
3.To report in writing to COUNTY immediately after discovery, the 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 services or activity under the terms of this
Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from equipment
purchased, which are incurred by CONTRACTOR, if prior written approval has not been obtained from
COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY’s DBH whenever
there is any modification or change in the use of any property acquired or improved, in whole or in part,
using funds under this Agreement. If any real or personal property acquired or improved with said funds
identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
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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.
21.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR and its subcontractors shall not
deny the contract’s benefits to any person on the basis of race, religious creed, color, national origin,
ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex,
gender, gender identity, gender expression, age, sexual orientation, or military and veteran status, nor
shall they discriminate unlawfully against any employee or applicant for employment because of race,
religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition,
genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual
orientation, or military or veteran status. CONTRACTOR shall insure that the evaluation and treatment of
employees and applicants for employment are free of such discrimination.
CONTRACTOR and subcontractors shall comply with the provisions of the Fair
Employment and Housing Act (Gov. Code §12800 et seq.), the regulations promulgated thereunder (Cal.
Code Regs., tit. 2, §11000 et seq.), the provisions of Article 9.5, Chapter 1, Part 1, Division 3, Title 2 of
the Government Code (Gov. Code §11135-11139.5), and the regulations or standards adopted by the
awarding state agency to implement such article. CONTRACTOR shall permit access by representatives
of the Department of Fair Employment and Housing and the awarding state agency upon reasonable
notice at any time during the normal business hours, but in no case less than twenty-four (24) hours
notice, to such of its books, records, accounts, and all other sources of information and its facilities as
said Department or Agency shall require to ascertain compliance with this clause. CONTRACTOR and
its subcontractors shall give written notice of their obligations under this clause to labor organizations with
which they have a collective bargaining or other agreement. (See Cal. Code Regs., tit. 2, §11105)
CONTRACTOR shall include the Non-Discrimination and compliance provisions of this clause in all
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subcontracts to perform work under this Agreement.
22.CULTURAL COMPENTENCY
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. The 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
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 language and
can effectively communicate any specialized terms and concepts peculiar to CONTRACTOR’s services.
E.In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
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COUNTY for approval, within sixty (60) days from date of contract execution, CONTRACTOR plan to
address all fifteen national cultural competency standards as set forth in the “National Standards on
Culturally and Linguistically Appropriate Services (CLAS)”
https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. 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 plan must be updated
accordingly. Cultural competency training for CONTRACTOR staff should be substantively integrated
into health professions education and training at all levels, both academic and functional, including core
curriculum, professional licensure, and continuing professional development programs.
CONTRACTOR on a monthly basis shall provide COUNTY DBH a monthly monitoring tool/report that
shows all CONTRACTOR staff cultural competency trainings completed.
F.CONTRACTOR shall be responsible for conducting an annual cultural competency
self-assessment and provide the results of said self-assessment to the COUNTY’S DBH. The annual
cultural competency self-assessment instruments shall be reviewed by the COUNTY and revised as
necessary to meet the approval of the COUNTY.
G.Cultural competency training for CONTRACTOR staff should be substantively
integrated into health professions education and training at all levels, both academic and functional,
including core curriculum, professional licensure, and continuing professional development programs. On
an annual basis, CONTRACTOR’s direct service providers shall complete eight (8) hours of cultural
competency training. CONTRACTOR on a monthly basis shall provide COUNTY DBH a monthly
monitoring tool/report that shows cultural competency trainings completed.
23.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,
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
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section 11135 codifies section 508 of the Act requiring accessibility of electronic and information
technology.
24.CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility for
planning and carrying out the services provided under this Agreement shall have any direct or indirect
personal financial interest in this Agreement. In addition, no employee of COUNTY shall be employed by
CONTRACTOR to fulfill any contractual obligations with COUNTY.
CONTRACTOR shall also comply with all Federal, State of California, and local conflict of
interest laws, statutes, and regulations, which shall be applicable to all parties and beneficiaries under this
Agreement and any officer, agent, or employee of COUNTY.
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.
///
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26.SINGLE AUDIT CLAUSE
A.If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars and No/100
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) 2 CFR 200. CONTRACTOR shall submit said audit and
management letter to COUNTY. The audit must include a statement of findings or a statement that there
were no findings. If there were negative findings, CONTRACTOR must include a corrective action plan
signed by an authorized individual. CONTRACTOR agrees to take action to correct any material non-
compliance or weakness found as a result of such audit. Such audit shall be delivered to COUNTY’s
DBH Business Office for review within nine (9) months of the end of any fiscal year in which funds were
expended and/or received for the program. Failure to perform the requisite audit functions as required by
this Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option,
contracting with a public accountant to perform said audit, or, may result in the inability of COUNTY to
enter into future agreements with CONTRACTOR. All audit costs related to this Agreement are the sole
responsibility of CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR’s Federal contracts do not
exceed the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or
CONTRACTOR’s only funding is through Drug-related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be submitted
by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR’s solvency. Said
audit report shall be delivered to COUNTY’s DBH Business Office for review, no later than nine (9)
months after the close of the fiscal year in which the funds supplied through this Agreement are
expended. Failure to comply with this Act may result in COUNTY performing the necessary audit tasks or
contracting with a qualified accountant to perform said audit. All audit costs related to this Agreement are
the sole responsibility of CONTRACTOR who agrees to take corrective action to eliminate any material
noncompliance or weakness found as a result of such audit. Audit work performed by COUNTY under
this Section shall be billed to the CONTRACTOR at COUNTY’s cost, as determined by COUNTY’s
Auditor-Controller/Treasurer-Tax Collector.
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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 the COUNTY’s Code of Conduct in accordance with
Exhibit H. Within thirty (30) days of entering into this Agreement with the COUNTY, CONTRACTOR shall
have all of CONTRACTOR’s employees, agents and subcontractors providing services under this
Agreement certify in writing, that he or she has received, read, understood, and shall abide by the
COUNTY’s Code of Conduct. 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 .
CONTRACTOR understands that the promotion of and adherence to the Code of Conduct is an element
in evaluating the performance of CONTRACTOR and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual who is
required to attend training shall certify in writing that he or she has received the required training. The
certification shall specify the type of training received and the date received. The certification shall be
provided to the COUNTY’s Compliance Officer at 1925 E. Dakota Ave., Fresno, California 93726.
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 it is not currently excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs: that it
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has not been convicted of a criminal offense related to the provision of health care items or services; nor
has it been reinstated to participation in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering into a contract, that
CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility
for, or involvement with, COUNTY’s business operations related to the Federal Health Care Programs
and shall remove such CONTRACTOR from any position in which CONTRACTOR’s compensation, or
the items or services rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part,
directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until such
time as CONTRACTOR is reinstated into participation in the Federal Health Care Programs.
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term of any
contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of any
claims submitted to any Federal Health Care Program. At its discretion given such circumstances,
COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or the
proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
under this Agreement, will be queried as to whether: (1) they are now or ever have been excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they
have been convicted of a criminal offense related to the provision of health care items or services; and or
(3) they have been reinstated to participation in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility.
1)In the event the potential employee or subcontractor informs
CONTRACTOR 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
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Agreement in accordance with Section Two (2) 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 timeframe to be determined by COUNTY
to protect the interests of COUNTY consumers.
C.CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement (1) are not currently excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have not
been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
CONTRACTOR 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 timeframe to be determined by COUNTY
to protect the interests of COUNTY clients.
D.CONTRACTOR agrees to cooperate fully with any reasonable requests for
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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.
29.PUBLIC PROHIBITION
None of the funds, materials, property or services provided directly or indirectly under this
Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e., purchasing of
tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the
above, publicity of the services described in Section One (1) of this Agreement shall be allowed as
necessary to raise public awareness about the availability of such specific services when approved in
advance by COUNTY’s DBH Director, or his or her designee, and at a cost to be provided in Exhibit C 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 (10th) 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-sponsored 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 F and
Exhibit I, “Fresno County Mental Health Plan – Grievances”, regarding grievances and incident reporting,
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attached hereto and by this reference incorporated herein and made a part of this Agreement.
31.CHILD ABUSE REPORTING ACT
CONTRACTOR shall establish a procedure acceptable to the COUNTY’s DBH Director, or
his or her designee, to ensure that all of the CONTRACTOR’s employees, consultants, subcontractors or
agents described in the Child Abuse Reporting Act, section 1116 et seq. of the Penal Code, and
performing services under this Agreement shall report all known or suspected child abuse or neglect to a
child protective agency as defined in Penal Code section 11165.9. This procedure shall include:
A.A requirement that all CONTRACTOR’s employees, consultants, subcontractors or
agents performing services shall sign a statement that he or she knows of and will comply with the
reporting requirements as defined in Penal Code section 11166(a), identified in Exhibit J, attached hereto
and incorporated herein by reference and made part of this Agreement.
B.Establishing procedures to ensure reporting even when employees, consultants,
subcontractors, or agents who are not required to report child abuse under Penal Code section 11166(a),
gain knowledge of or reasonably suspect that a child has been a victim of abuse or neglect.
32.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104, and
455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR by completing Exhibit 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 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. CONTRACTOR is
required to submit a set of fingerprints for any person with a five (5) percent or greater direct or indirect
ownership interest in CONTRACTOR. COUNTY may terminate this Agreement where any person with a
five (5) percent or greater direct or indirect ownership interest in the CONTRACTOR did not submit timely
and accurate information and cooperate with any screening method required in CFR, Title 42, Section
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455.416. Submissions shall be scanned portable document format (pdf) copies and are to be sent via
email to DBHAdministration@fresnocountyca.gov, Attention: Contracts Administration. COUNTY may
deny enrollment or terminate this Agreement where any person with a five (5) percent or greater direct or
indirect ownership interest in CONTRACTOR has been convicted of a criminal offense related to that
person’s involvement with the Medicare, Medicaid, or Title XXI program in the last ten (10) years.
33.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 as
“CONTRACTOR”):
A.Within the three (3) year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1)Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or
contract under a public transaction;
2)Violation of a federal or state antitrust statute;
3)Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
or
4)False statements or receipt of stolen property.
B.Within a three (3) year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR from
further business consideration. The information will be considered as part of the determination of whether
to continue and/or renew the Agreement and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that the CONTRACTOR failed to disclose required information, any contract awarded to such
CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms
and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
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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 the COUNTY 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 the COUNTY harmless for any loss or damage
resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed
Certification Regarding Debarment, Suspension, and Other Responsibility Matters.
34.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR changes its
status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this Agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR is
a party and in which one or more of its directors has a material financial interest. Members of the Board
of Directors shall disclose any self-dealing transactions that they are a party to by completing and signing
a “Self-Dealing Transaction Disclosure Form”, attached hereto as Exhibit M and incorporated herein by
reference and made part of this Agreement, and submitting it to the COUNTY prior to commencing with
the self-dealing transaction or immediately thereafter.
35.SUBCONTRACTS
CONTRACTOR shall obtain written approval from COUNTY’s DBH Director, or designee,
before subcontracting any of the services delivered under this Agreement. COUNTY’s DBH Director, or
designee, retains the right to approve or reject any request for subcontracting services. Any transferee,
assignee, or subcontractor will be subject to all applicable provisions of this Agreement, and all applicable
State and Federal regulations. CONTRACTOR shall be held primarily responsible by COUNTY for the
performance of any transferee, assignee, or subcontractor unless otherwise expressly agreed to in writing
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by COUNTY’s DBH Director, or designee. The use of subcontractors by CONTRACTOR shall not entitle
CONTRACTOR to any additional compensation that is provided for under this Agreement.
36.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.
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 of California Auditor General
for a period of three (3) years after final payment under contract (California Government Code section
8546.7).
37.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, County of Fresno Chief Financial Officer
Department of Behavioral Health Hinds Hospice
PO BOX 1912 2490 W. Shaw Ave
Fresno, CA 93718-1912 Fresno, CA 93711
All notices between the COUNTY and CONTRACTOR provided for or permitted under this
Agreement must be in writing and delivered either by personal service, by first-class United States mail,
by an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three (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
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notice delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if
such transmission is completed outside of COUNTY business hours, then such delivery shall be deemed
to be effective at the next beginning of a COUNTY business day), provided that the sender maintains a
machine record of the completed transmission. For all claims arising out of or related to this Agreement,
nothing in this Section establishes, waives, or modifies any claims presentation requirements or
procedures provided by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1
of the Government Code, beginning with Section 810).
38.SEVERABILITY
If any non-material term, provision, covenant, or condition of this Agreement is held by a
court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions shall
remain in full force and effect, and shall in no way be affected, impaired or invalidated.
39.GOVERNING LAW
Venue for any action arising out of or related to the Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
40.ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
2 f irst hereinabove written .
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CONTRACTOR:
(Authorized Signfuture)
Print Name & T itle '
12 ~eSY\.o CA °13 ]I I
Mai ling Addres~
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21 FOR ACCOUNTING USE ONLY:
22 ORG No.:
Account No .:
23 Fund /Subclass :
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56304776
7295/0
0001 /10000
32
COUNTY OF FRESNO
Nathan Magsig , Chairman of the Board
of Supervisors of the County of Fresno
ATTEST:
Bernice E . Seidel
Clerk of the Board of Supervisors
County of Fresno , State of California
By: ~ ~s.b~
Deputy
Exhibit A - Page 1 of 9
SUMMARY OF SERVICES
ORGANIZATION: Hinds Hospice
PROGRAM NAME: Center for Grief and Healing – Survivors of Suicide Loss
SERVICE: Local Outreach to Suicide Survivors (LOSS) Team
OFFICE ADDRESS: 2490 W. Shaw Ave., Fresno, CA 93711
OFFICE TELEPHONE: (559) 248-8579
CONTACT(S): Kathleen Cromwell, Program Director
Brandy Lidbeck, Program Coordinator
CONTRACT PERIOD: Effective Upon Execution – June 30, 2022
With two possible 12-month extensions
AMOUNT: Effective Upon Execution – June 30, 2019: $85,485
FY 19-20: $337,777
FY 20-21: $346,631
FY 21-22: $351,860
FY 22-23: $355,489
FY 23-24: $360,622
A.SUMMARY OF SERVICES
CONTRACTOR shall provide a Local Outreach to Suicide Survivors (LOSS) team in
Fresno County to provide information, support, warm linkage, and resources to
newly bereaved suicide survivors. The principle of a LOSS Team is essentially one
of providing hope through connecting with survivors at the time of the loss. The
LOSS Team consists of trained professionals and volunteers to bring immediate
support to survivors of suicide. The LOSS Team is activated by first response
officials when a suicide occurs to provide resources, support, and hope to suicide
survivors. The LOSS Team provide immediate assistance to survivors to help them
cope with the trauma of their loss, provide follow-up contact with the survivors, and
coordinate the utilization of services and support groups within the community.
B.TARGET POPULATION
Services will be provided to family members and loved ones of the deceased, both
adults and children, and will extend into their workplace and communities.
Exhibit A - Page 2 of 9
C. REFERRALS
Referrals for immediate response will primarily come from law enforcement dispatch
and the coroner’s office.
Individuals that reside in our county and the death occurred out of county, referrals
will be from chaplain services, medical providers, community organizations and self-
referrals.
D. LOCATION OF SERVICES
Services will be provided at The Center for Grief & Healing as well as in the field,
both metro and rural areas. Services will not be provided outside of Fresno County.
E. IMPLEMENTATION AND HOURS OF OPERATION
Services will eventually be available 7 days a week, 24 hours a day. Starting off,
Services will be implemented in the phases identified below. Dates indicated below
are estimates and may change with the approval of DBH and Contractor.
Phase 1: Month 1 - 3
• Program development-establishment of policies and procedures
• Volunteer recruitment, processing and training
• Community outreach
• Establishing protocol for referrals
• Delayed response provided
Phase 2: Month 4 – 8
• Begin immediate response by LOSS Team. Monday - Friday, 8:00AM-
5:00PM (Metro Area only)
• All other suicides will receive delayed response by the LOSS Team.
Phase 3: Month 9 – 12
• Hours of operation will expand to 6:00AM – 12:00AM, 7 days a week (Metro
Area only)
• All other suicides will receive delayed response by the Loss Team.
Phase 4: Month 13 – End of Contract
• Services will be fully operational in Fresno County. Immediate response will
be available in both metro and rural areas. Services will be available 7 days a
week, 24 hours a day.
• Should immediate response be unavailable, LOSS Team will provide a
delayed response to family members and loved ones of the deceased, both
adults and children, and will extend into their workplace and communities.
Exhibit A - Page 3 of 9
F.CONTRACTOR’s RESPONSIBILITIES
CONTRACTOR shall perform the activities below.
1.Provide Community Response (Active and/or Delayed Response)
LOSS Team will respond to support survivors of suicide loss in homes, hospitals,
and on-scene after a suicide is determined.
a.Active Response – Outreach to survivors at the scene of the death.
b.Delayed Response – Outreach after some time has passed. Reasons for a
delayed response may include but is not limited to:
i.Survivor refuses immediate support services;
ii.LOSS Team is unable to respond on scene; and
iii.Manner of death was not determined on scene.
2.Provide Resources to the Survivors of Suicide Loss
A Resource packet or package shall be provided to Survivors of Suicide Loss.
Contents may include but are not limited to blankets, journals, magnets with
resource numbers, websites, books, list of organizations to help survivors,
funeral planning information and a checklist of business items that must be done
after a loved one passes away. Child specific resources may also be included.
3.Provide Debriefings for Survivors, Contractor’s Staff and Volunteers
Debriefing sessions will take place following the LOSS call for individuals
involved in order to reduce the potential trauma impact and compassion fatigue.
4.Provide Individual and Couples Therapy
Six (6) therapy sessions shall be made available to all survivors.
Sessions are free of charge and conducted by licensed clinicians and/or
associate. Evidence-based therapeutic intervention practices will be used.
5.Provide Support Groups
a.Peer-run support group will be offered twice a month. Support groups will be
facilitated by volunteer survivors with a mental health clinician present.
b.Suicide-loss therapy support groups – Three (3) 12-week sessions shall be
offered each FY. Support groups will be facilitated by a mental health
clinician.
6.Provide Bereavement Support
a.Support Phone Calls – A minimum of four phone calls shall be made
throughout the first year to check-in with families and remind them of the
supports available.
b.Bereavement Mailings - Letters and articles will be sent to the family’s home
for a period of 13 months which offer education and support.
c.Workshops/Trainings - A variety of workshops shall be made available to
families. Workshops should educate families on typical grief and loss
reactions and experiences.
Exhibit A - Page 4 of 9
d. Peer Connection – New survivors shall have the opportunity to connect with
another survivor further along in their grief journey to offer ongoing support
and connection.
7. Provide Outreach and Support to the Community
a. CONTRACTOR shall educate the community regarding the LOSS Team.
b. CONTRACTOR shall offer suicide prevention training to the community and
law enforcement/first responders.
c. CONTRACTOR may host and/or participate in community run/walk/events to
allow survivors the annual opportunity to connect with one another and
remember/honor their loved one while raising awareness of suicide
prevention. Activities may include but are not limited to: Annual memorial
event, Paint night, Moms 2 Moms gatherings, etc.
d. CONTRACTOR may work with business/organizations to respond on-site to
debrief and offer support after a suicide loss.
8. Develop Partnerships with the Coroner and Law Enforcement
CONTRACTOR shall develop partnerships with the coroner or medical examiner,
police department (or other law enforcement unit), or chaplains affiliated with the
police department. CONTRACTOR shall work with the agency to establish
procedures regarding data sharing and referrals. Should a Memorandum of
Understanding (MOU) be established, a copy shall be provided to DBH.
9. Compliance with County
CONTRACTOR shall comply with all contract monitoring and compliance
protocols, procedures, data collection methods, and reporting requirements
conducted by the COUNTY.
10. Participate in DBH Meetings
Supervisory and/or Management staff shall participate in meetings to discuss
program and/or contractual issues. DBH shall coordinate the meetings.
G. CONTRACTOR’s STAFF
1. CONTRACTOR shall recruit and maintain staffing in accordance with Exhibit C,
Budget Summary.
2. Additions, deletions or other changes to CONTRACTOR's staff shall be approved
by DBH prior to implementing staff changes. CONTRACTOR shall submit a
budget modification form indicating the changes and related dollar amounts.
3. CONTRACTOR may subcontract to fill staffing positions identified in Exhibit C.
CONTRACTOR shall obtain approval from COUNTY’s DBH Director, or
designee, before subcontracting any of the services delivered under this
Agreement.
Exhibit A - Page 5 of 9
4. CONTRACTOR shall provide training opportunities to staff and volunteers, as
needed, to improve and maintain outcomes, skills, best practice and cultural
competency. Trainings may include but are not limited to the following:
a. Mental Health First Aid
b. Youth Mental Health First Aid
c. Health Equity & Multicultural Diversity
d. Suicide Prevention Education
5. CONTRACTOR shall recruit volunteers (suicide loss survivors) to co-respond
with clinicians during an active response. Volunteers should clear background
checks and be trained prior to responding on calls. Stipends will be provided to
the volunteers per visit.
6. CONTRACTOR shall provide support to the volunteer survivors as well as staff
on a monthly basis.
7. Debriefings for Clinicians and Volunteers – CONTRACTOR shall hold debriefing
sessions following LOSS calls for those involved in order to reduce the potential
trauma impact and compassion fatigue.
H. REPORTS
1. CONTRACTOR shall capture required Prevention and Early Intervention (PEI)
demographics data and comply with PEI reporting requirements as set forth in
PEI Regulations (http://mhsoac.ca.gov/laws-and-regulations).
2. CONTRACTOR shall be expected to comply with all contract monitoring and
compliance protocols, procedures, data collection methods, and reporting
requirements conducted by the COUNTY.
3. Additional reports/outcomes may also be requested by the COUNTY’s DBH,
based on among other things, identification of client/family specific needs as well
as State required reports/outcomes as needed.
I. PERFORMANCE OUTCOME MEASURES
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 as Exhibit D. Performance outcomes
measures must be approved by COUNTY’s DBH and satisfy all State and local
mandates. COUNTY’s DBH will provide technical assistance and support in defining
measureable outcomes. All performance indicators will reflect the four (4) domains
identified by the Commission Accreditation of Rehabilitation Facilities (CARF). The
domains are Effectiveness, Efficiency, Access, and Satisfaction. These are defined
and listed below.
Exhibit A - Page 6 of 9
COUNTY’s DBH 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 (1) performance indicator will be identified for each of the
four (4) CARF domains listed below.
a.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.
b.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.
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.
c.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.
d.Satisfaction: Satisfaction Measures are usually orientated towards clients,
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,
client and/or Treatment Perception Survey.
Exhibit A - Page 7 of 9
CONTRACTOR must address each of the categories referenced above and any
additional 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 this Agreement, as needed, to best measure the program as determined
by the COUNTY. CONTRACTOR will be required to utilize and integrate clinical
tools as directed by DBH.
In addition to the requirements set above, the following items listed below represent
program goals and outcomes to be achieved by CONTRACTOR. Identified goals
and outcomes are considered preliminary and may be modified, by mutual consent,
by DBH Director, or designee, and by CONTRACTOR during the contract term.
CONTRACTOR will report goals and outcomes in a method determined by DBH.
1. Goals and Outcomes
a. The LOSS Team will provide an active or delayed response to 50% of all
suicide losses in the 1st year.
b. The Loss Team will provide an active or delayed response to 60% of all
suicide losses in the 2nd and all succeeding years
c. 60% of survivors will access grief support services through Hinds Hospice.
d. Conduct four trainings a year with community organizations (Faith supports,
Social Workers, Hospitals) on how to provide support to those impacted by
suicide, while also increasing networking referrals.
e. Improvement of distressing symptoms related to grief in clients receiving
services.
f. Maintain data collection and report findings/trends to Department of
Behavioral Health, and the suicide collaborative, in order to better serve
survivors, and to decrease the suicide rate.
2. Data Tracking
a. Total number of unduplicated individuals who engaged in services.
b. Total number of unduplicated individuals who enter therapy services
c. Total number of unduplicated individuals who participate in support groups
d. Total number of individuals who were referred out or linked to other external
services
e. Total number of completed sessions and the needs beyond the initial six
sessions offered.
Exhibit A - Page 8 of 9
3. Data Collection
a. CONTRACTOR will attempt to collect the following demographics:
i. Race
ii. Ethnicity
iii. Age/DOB
iv. Disabilities
v. Preferred Language
vi. Gender Identity Now
vii. Gender assigned at birth
viii. Sexual Orientation
ix. Veteran Status
x. Children in the home
xi. Suicide Loss History
xii. Address
xiii. Referrals for crisis intervention due to safety concerns
xiv. Mode of death
xv. Presence of suicide note
xvi. Who found the deceased
xvii. Time elapsed from death to engagement of services
b. Data collection and evaluation methods may include, but are not limited to,
staff, participants, interviews, surveys, and evaluations.
c. CONTRACTOR shall ensure all program clients/families participate in the
semi-annual State Consumer Perception Survey (CPS) survey. CPS’s will be
distributed to all active clients/families to fill out and return to CONTRACTOR.
J. COUNTY’s RESPONSIBILITIES
County shall:
1. Participate in monthly meetings with CONTRACTOR to discuss program and/or
contractual issues. Meetings frequency may be changed after the first year of
implementation. DBH will be responsible for coordination of these meetings.
2. Participate in evaluating the progress of the overall program and the efficiency of
collaboration with CONTRACTOR’s staff and will be available to the
CONTRACTOR for ongoing consultation.
Exhibit A - Page 9 of 9
3. Gather outcome information from CONTRACTOR throughout each term of this
Agreement. COUNTY DBH staff shall notify the 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.
4. Assist the CONTRACTOR’s efforts towards cultural and linguistic competency by
providing the following to CONTRACTOR:
a. Technical assistance and training regarding cultural competency
requirements.
b. Mandatory cultural competency training for CONTRACTOR personnel, at
minimum once per year.
c. Technical assistance for translating information into COUNTY’s threshold
languages (Spanish and Hmong). Translation services and costs
associated will be the responsibility of the CONTRACTOR.
5. DBH shall include CONTRACTOR's staff in DBH trainings that are relevant to the
services as described in this Agreement, if there is sufficient space available, at
no cost.
Guiding Principles of Care Delivery
1
rev 2017 Dec
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
•Deliver quality care
•Maximize resources while focusing on efficiency
•Provide an excellent care experience
•Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit B - Page 1 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2
rev 2017 Dec
2.Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3.Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4.Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5.Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit B - Page 2 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
3
rev 2017 Dec
6.Principle Six - Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7.Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8.Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9.Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit B - Page 3 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
4
rev 2017 Dec
10.Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11.Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit B - Page 4 of 4
Fresno County Department of Behavioral Health
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Program Director 0.20 $111,927 $5,596
0002 Program Coordinator 1.00 $68,640 $17,160
0003 On-Call 0.00 $13,000
0004 On-Call 0.00 $13,000
0005 On-Call 0.00 $13,000
0006 After Hour Response 0.00 $11,880
0007 Licensed Clinician 0.40 $66,560 $6,656
0008 Admin Program Support Staff 0.40 $37,440 $3,744
SALARY TOTAL 2.00 $0 $335,447 $33,156
PAYROLL TAXES:
0030 OASDI $2,429
0031 FICA/MEDICARE $4,192
0032 SUI $4,421
PAYROLL TAX TOTAL $11,042
EMPLOYEE BENEFITS:
0040 Retirement $548
0041 Workers Compensation $1,137
0042 Health Insurance (medical, vision, life, dental)$6,277
EMPLOYEE BENEFITS TOTAL $7,962
SALARY & BENEFITS GRAND TOTAL $52,160
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $2,007
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $2,007
Line Item Description (Must be itemized)
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
Budget Categories -Total Proposed Budget
FY 2018-2019 (3 months: April 2019 - June 2019)
Exhibit C - Page 1 of 47
OPERATING EXPENSES:
1060 Telephone/Cell Phone $1,115
1061 Answering Service $0
1062 Postage/Mailing $1,000
1063 Printing/Reproduction $500
1064 Publications $0
1065 Legal Notices/Advertising/Outreach $625
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies $2,225
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $624
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $5,000
1075 Lodging $0
1076 IT Support $1,125
1077 Background Checks $4,950
1078 Uniforms and Badges $3,300
1079 Interpreter Services $0
OPERATING EXPENSES TOTAL $20,464
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $830
1083 Administrative Overhead $6,024
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $6,854
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)$0
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $0
FIXED ASSETS:
1190 Computers & Software $2,000
1191 Furniture & Fixtures $2,000
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $4,000
Exhibit C - Page 2 of 47
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)$0
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing, Food & Hygiene (SFC 72)$0
2002.2 Client Transportation & Support (SFC 72)$0
2002.3 Education Support (SFC 72)$0
2002.4 Employment Support (SFC 72)$0
2002.5 Respite Care (SFC 72)$0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $0
TOTAL PROGRAM EXPENSES $85,485
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 $0.00 $0
3100 Case Management 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Collateral 0 $0.00 $0
3500 Plan Development 0 $0.00 $0
3600 Assessment 0 $0.00 $0
3700 Rehabilitation 0 $0.00 $0
Estimated Specialty Mental Health Services Billing Totals 0 $0
Estimated % of Clients that are Medi-Cal Beneficiaries 0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $0
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 0.00%$0
State M/Cal Share of Cost % (BH Realignment/EPSDT) 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)$0
4100 Other - (Identify)$0
4200 Other - (Identify)$0
4300 Other - (Identify)$0
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $85,485
5100 Community Services & Supports (CSS) Funds $0
5200 Innovation (INN) Funds $0
5300 Workforce Education & Training (WET) Funds $0
MHSA FUNDS TOTAL $85,485
TOTAL PROGRAM REVENUE $85,485
Exhibit C - Page 3 of 47
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
0001
0002
0007
0008
0030
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2018-2019 (3 months: April 2019 - June 2019)
Budget Narrative - Expenses
One (1) Director of Center for Grief and Healing
($111,927 Annual Base Salary) x (.2 FTE) x (3 Months) / (12 Months) = $5,596
Responsible for developing, coordinating, supervising, providing and/or assuring
provision of bereavement services to hospice families and to the community at
large. The Director of the Center for Grief and Healing is responsible for all aspects
of the various bereavement programs and provides supervision to staff and
volunteers involved in the Bereavement Program. In addition, this position will also
provide direct services to clients.
One (1) SOSL Program Coordinator
($68,640 Annual Base Salary) x (1 FTE) x (3 Months) / (12 Months) = $17,160
Responsible for coordinating grief support services for survivors, community
education, and outreach, to include suicide prevention education. They will also
provide both individual, family and group counseling services. Other duties include
the LOSS team, management of on-call staff and volunteers.
One (1) Licensed Clinician
($66,560 Annual Base Salary) x (.4 FTE) x (3 Months) / (12 Months) = $6,656
Provides support to grieving individuals, couples, and families. Facilitates support
groups.
One (1) Admin Program Support
($37,440 Annual Base Salary) x (.4 FTE) x (3 Months) / (12 Months) = $3,744
Responsible for collecting and recording all client data. This individual will assemble
all materials and resources given to families and first responders. This individual
will work directly with the Program Coordinator to facilitate survivor support services
and distribution of satisfaction surveys.
OASDI
OASDI will be paid in a like manner as other employees of Hinds Hospice. ($2,429)
Exhibit C - Page 4 of 47
0031
0032
0040
0041
0042
Facilities/Equipment Expenses – Line Items 1010-1014
1010
Operating Expenses - Line Items 1060-1077
1060
1062
1063
Rent expense is all inclusive and includes space, utilities and housekeeping at a
rate of $1 per square foot per month. The program will occupy approximately 669
square of office space at $1 per foot for 12 months which totals $8,028 annually.
($8,028 / 12 months x 3 month ramp up = $2,007)
Telephone/Internet/Cell Phone
Phone and Internet - Estimated at $92/mo x 3 months = $275
Cell Phones - Estimated at 4 Positions x $70/mo x 3 months = $840
Agency issued cellphones are for business use only.
Postage/Mailing
Postage will be used to mail out miscellaneous informational resource packets to
families both local and non-local. Cost is estimated @ $125.
Mailings include bereavement mailings, informational resource packets to families,
and invitations to special events. Cost is estimated @ $875.
Printing/Reproduction
In-house printing, business cards, flyers, folders and brochures, given to each
family, etc. Costs are estimated @ $500.
SUI
SUI will be paid in a like manner as other employees of Hinds Hospice. ($4,421)
Retirement
Retirement will be paid in a like manner as other employees of Hinds Hospice.
($548)
Workers Compensation
Workers Compensation will be paid in a like manner as other employees of Hinds
Hospice. ($1,137)
Health Insurance (medical, vision, life, dental)
Health Insurance will be paid in a like manner as other employees of Hinds
Hospice. ($6,277)
FICA/MEDICARE
FICA/MEDICARE will be paid in a like manner as other employees of Hinds
Hospice. ($4,192)
Exhibit C - Page 5 of 47
1065
1069
1072
1074
1076
1077
1078
Financial Services Expenses – Line Items 1080-1085
1082 Liability Insurance
General liability insurance cost is estimated at $830 for the three month term.
IT Support
IT Support includes technology support and system security. Cost is estimated @
$1,125 per year.
Background Checks
Background checks are conducted on each LOSS Team members (staff and
volunteers) to ensure safety and protection of the community as the LOSS Team
enters into the homes and workplaces of survivors. Estimated at 30 individuals x
$165/each = $4,950.
Uniforms and Badges
All LOSS team members (staff and volunteers) will wear a designated uniform to
provide professionalism to each on-scene call. Uniforms may consist of collared
shirts and jackets with the official LOSS Team logo. 50 shirts @ $15= $750, 50
jackets @ $40= $2000, 50 nametags @ $5 = $ 250 + set-up and tax $300 =
$3300.
Staff Training/Registration
This will include the initial training for all volunteers and clinicians on how to
appropriately respond to a LOSS call. This will be facilitated by associates of the
national LOSS Team consultants. After the initial training, this will be used for
ongoing education, trainings and LOSS Team conferences. Cost is estimated @
$5000.
Legal Notices/Advertising/Outreach
Folders, flyers, envelopes and other materials used to advertise the LOSS team to
both gather volunteers as well as inform 1st responders and other key stakeholders
of the presence of the LOSS team. Cost is estimated @ $625.
Program Supplies
Supplies include but are not limited to suicide grief books for children, variety of
resources from American Foundation for Suicide Prevention (AFSP) and Suicide
Awareness Voices of Education (SAVE), and kits to each family (i.e.. Blankets,
journals, etc.). Cost is estimated @ $2,225.
Staff Mileage/vehicle maintenance
Reimbursement of mileage used to respond to on-scene active and delayed calls.
Estimated 31 responses x 35 miles round trip each x $.57= $624.
Exhibit C - Page 6 of 47
1083
Fixed Assets – Line Items 1190-1193
1190
1191
Computer and Software
Includes 4 computers (as well as printers) and software. Cost is estimated at
$2,000.
Furniture and Fixtures
Includes office chairs and desk. Cost is estimated at $2,000.
Administrative Overhead
Indirect costs are those costs of general management that are agency-wide.
General management costs consist of expenditures for administrative activities
necessary for the general operation of Hinds Hospice (e.g., accounting, budgeting,
payroll preparation, personnel management, purchasing, and centralized data
processing). ($6,024)
TOTAL PROGRAM EXPENSE:$85,485
Exhibit C - Page 7 of 47
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Program Director 0.20 $111,927 $22,385
0002 Program Coordinator 1.00 $68,640 $68,640
0003 On-Call 1.00 $13,000 $13,000
0004 On-Call 1.00 $13,000 $13,000
0005 On-Call 1.00 $13,000 $13,000
0006 After Hour Response 1.00 $11,880 $11,880
0007 Licensed Clinician 0.40 $66,560 $26,624
0008 Admin Program Support Staff 0.40 $37,440 $14,976
SALARY TOTAL 6.00 $0 $335,447 $183,505
PAYROLL TAXES:
0030 OASDI $12,871
0031 FICA/MEDICARE $15,549
0032 SUI $5,638
PAYROLL TAX TOTAL $0 $0 $34,058
EMPLOYEE BENEFITS:
0040 Retirement $2,914
0041 Workers Compensation $6,026
0042 Health Insurance (medical, vision, life, dental)$28,769
EMPLOYEE BENEFITS TOTAL $0 $0 $37,709
SALARY & BENEFITS GRAND TOTAL $255,272
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $8,028
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $8,028
Line Item Description (Must be itemized)
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
Budget Categories -Total Proposed Budget
FY 2019-2020
Exhibit C - Page 8 of 47
OPERATING EXPENSES:
1060 Telephone/Cell Phone $4,460
1061 Answering Service $1,275
1062 Postage/Mailing $4,000
1063 Printing/Reproduction $2,000
1064 Publications $0
1065 Legal Notices/Advertising/Outreach $6,500
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies $8,900
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $2,494
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $1,250
1075 Lodging $0
1076 IT Support $4,500
1077 Background Checks $1,320
1078 Uniforms and Badges $825
1079 Interpreter Services $2,535
OPERATING EXPENSES TOTAL $40,059.00
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $3,320
1083 Administrative Overhead $24,097
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $27,417
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant/Volunteer Stipends $7,000
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $7,000
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
Exhibit C - Page 9 of 47
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)$0
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing, Food & Hygiene (SFC 72)$0
2002.2 Client Transportation & Support (SFC 72)$0
2002.3 Education Support (SFC 72)$0
2002.4 Employment Support (SFC 72)$0
2002.5 Respite Care (SFC 72)$0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $0
TOTAL PROGRAM EXPENSES $337,777
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 $0.00 $0
3100 Case Management 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Collateral 0 $0.00 $0
3500 Plan Development 0 $0.00 $0
3600 Assessment 0 $0.00 $0
3700 Rehabilitation 0 $0.00 $0
Estimated Specialty Mental Health Services Billing Totals 0 $0
Estimated % of Clients that are Medi-Cal Beneficiaries 0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $0
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 0.00%$0
State M/Cal Share of Cost % (BH Realignment/EPSDT) 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)$0
4100 Other - (Identify)$0
4200 Other - (Identify)$0
4300 Other - (Identify)$0
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $337,777
5100 Community Services & Supports (CSS) Funds $0
5200 Innovation (INN) Funds $0
5300 Workforce Education & Training (WET) Funds $0
MHSA FUNDS TOTAL $337,777
TOTAL PROGRAM REVENUE $337,777
Exhibit C - Page 10 of 47
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
0001
0002
0003 - 0005
One (1) Director of Center for Grief and Healing
($111,927 Annual Base Salary) x (.2 FTE) = $22,385
Responsible for developing, coordinating, supervising, providing and/or assuring
provision of bereavement services to hospice families and to the community at
large. The Director of the Center for Grief and Healing is responsible for all aspects
of the various bereavement programs and provides supervision to staff and
volunteers involved in the Bereavement Program. In addition, this position will also
provide direct services to clients.
One (1) SOSL Program Coordinator
($68,640 Annual Base Salary) x (1 FTE) = $68,640
Responsible for coordinating grief support services for survivors, community
education, and outreach, to include suicide prevention education. They will also
provide both individual, family and group counseling services. Other duties include
the LOSS team, management of on-call staff and volunteers.
Three (3) On-Call Clinicians
($13,000 Annual Base Salary) x (1 FTE) x 3 Positions = $39,000
Takes calls seven (7) days in a work-period (weekdays, weekends, and holidays)
after the agency’s normal working hours. This wage compensates the employee for
being available for immediate response to Loss Team requests. When a request is
received, the employee will be paid as position 0006 On-Call Response, which is
compensation for call duty. There are a total of 123 hours of on-call shifts per week.
These shifts will be covered by 3 employees with an average on-call schedule of 41
hours each per week. Clinicians are required for this position due to the nature of
the trauma related to suicide death and the impact on survivors, including the risk
of survivors becoming suicidal. It is also the role of the clinician to provide support
and guidance to the suicide loss survivor volunteer and first responders.
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2019-2020
Budget Narrative - Expenses
Exhibit C - Page 11 of 47
0006
0007
0008
0030
0031
0032
0040
SUI
SUI will be paid in a like manner as other employees of Hinds Hospice. ($5,638)
Retirement
Retirement will be paid in a like manner as other employees of Hinds Hospice.
($2,914)
FICA/MEDICARE
FICA/MEDICARE will be paid in a like manner as other employees of Hinds
Hospice. ($15,549)
One (1) FTE After Hour Response Clinician
($30/hr x 288 response hours) x ($45/hr x 72 OT hours) = $11,880
It is estimated that 288 hours will be paid at the base rate of $30/hr and that the
remaining 72 hours will be paid at an overtime of $45/hr. The position provides
direct Active Loss on-scene support to survivors immediately after dispatched.
Clinicians are required for this position due to the nature of the trauma related to
suicide death and the impact on survivors, including the risk of survivors becoming
suicidal. It is also the role of the clinician to provide support and guidance to suicide
loss survivor volunteers and first responders. We estimated that 60% of suicides
will take place outside of normal business hours or approximately 72 per year. Each
response is expected to take 3 hours, which includes travel and volunteer
debriefing. Approximately, one-third of these hours are estimated to be paid at an
over-time rate.
One (1) Licensed Clinician
($66,560 Annual Base Salary) x (.4 FTE) = $26,656
Provides support to grieving individuals, couples, and families. Facilitates support
groups.
One (1) Admin Program Support
($37,440 Annual Base Salary) x (.4 FTE) = $14,976
Responsible for collecting and recording all client data. This individual will assemble
all materials and resources given to families and first responders. This individual
will work directly with the Program Coordinator to facilitate survivor support services
and distribution of satisfaction surveys.
OASDI
OASDI will be paid in a like manner as other employees of Hinds Hospice.
($12,871)
Exhibit C - Page 12 of 47
0041
0042
Facilities/Equipment Expenses – Line Items 1010-1014
1010
Operating Expenses - Line Items 1060-1077
1060
1061
1062
1063
1065
Workers Compensation
Workers Compensation will be paid in a like manner as other employees of Hinds
Hospice. ($6,026)
Health Insurance (medical, vision, life, dental)
Health Insurance will be paid in a like manner as other employees of Hinds
Hospice. ($28,769)
Rent expense is all inclusive and includes space, utilities and housekeeping at a
rate of $1 per square foot per month. The program will occupy approximately 669
square of office space at $1 per foot for 12 months which totals $8,028 annually.
Telephone/Internet/Cell Phone
Phone and Internet - Estimated at $92/mo x 12 months = $1,100
Cell Phones - Estimated at 4 Positions x $70/mo x 12 months = $3,360
Agency issued cellphones are for business use only.
Answering Services
This service documents every call and dispatches to the On-Call Clinician for
response. Used to receive calls after hours, weekends, and holidays. Estimated
@75 calls after hours x $17 = $1,275.
Postage/Mailing
Postage will be used to mail out miscellaneous informational resource packets to
families both local and non-local. Cost is estimated @ $500
Mailings include bereavement mailings, informational resource packets to families,
and invitations to special events. Estimated at $7.50/ person (for 1 year of mailings)
x 350 people + 8 labor hours/week= $3,500
Printing/Reproduction
In-house printing, business cards, flyers, folders and brochures, given to each
family, etc. Costs are estimated @ $2,000
Legal Notices/Advertising/Outreach
Folders, flyers, envelopes and other materials used to advertise the LOSS team to
both gather volunteers as well as inform 1st responders and other key stakeholders
of the presence of the LOSS team. Cost is estimated @ $2,500)
Outreach activities/events used to connect with the community and survivors such
as a run/walk. Cost is estimated @ $4,000
Exhibit C - Page 13 of 47
1069
1072
1074
1076
1077
1078
1079
Financial Services Expenses – Line Items 1080-1085
1082
Staff Training/Registration
This will include the initial training for all volunteers and clinicians on how to
appropriately respond to a LOSS call. This will be facilitated by associates of the
national LOSS Team consultants. After the initial training, this will be used for
ongoing education, trainings and LOSS Team conferences. Cost is estimated @
$1,250.
IT Support
IT Support includes technology support and system security. Cost is estimated @
$4,500 per year.
Background Checks
Background checks are conducted on each LOSS Team members (staff and
volunteers) to ensure safety and protection of the community as the LOSS Team
enters into the homes and workplaces of survivors. Estimated at 8 individuals x
$165/each = $1,320.
Uniforms and Badges
All LOSS team members (staff and volunteers) will wear a designated uniform to
provide professionalism to each on-scene call. Uniforms may consist of collared
shirts and jackets with the official LOSS Team logo. 10 shirts @ $15= $150, 10
jackets @ $40= $400, 10 nametags @ $5 = $ 50 + set-up and tax $225 = $825.
Interpreter Services
Interpreter rates = $65/hr (required minimum 2 hours +1 hr travel = 3 hours) = $195
x 13 estimated service calls = $2,535.
Liability Insurance
General liability insurance cost is estimated at $3,320 for the 12 month term.
Staff Mileage/vehicle maintenance
Reimbursement of mileage used to respond to on-scene active and delayed calls.
Estimated 125 responses x 35 miles round trip each x $.57= $2,494.
Program Supplies
Supplies include but are not limited to suicide grief books for children, variety of
resources from American Foundation for Suicide Prevention (AFSP) and Suicide
Awareness Voices of Education (SAVE), and kits to each family (i.e.. Blankets,
journals, etc.). Cost is estimated @ $8,900.
Exhibit C - Page 14 of 47
1083
Special Expenses – Line Items 1090-1092
1090 Consultants/Volunteer Stipends
Volunteers will receive a $50 stipend to attend each LOSS call response. Cost is
estimated based off 140 responses. $50 x $140 = $7,000.
TOTAL PROGRAM EXPENSE:$337,777
Administrative Overhead
Indirect costs are those costs of general management that are agency-wide.
General management costs consist of expenditures for administrative activities
necessary for the general operation of Hinds Hospice (e.g., accounting, budgeting,
payroll preparation, personnel management, purchasing, and centralized data
processing). ($24,097)
Exhibit C - Page 15 of 47
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Program Director 0.20 $111,927 $22,385
0002 Program Coordinator 1.00 $68,640 $68,640
0003 On-Call 1.00 $13,000 $13,000
0004 On-Call 1.00 $13,000 $13,000
0005 On-Call 1.00 $13,000 $13,000
0006 After Hour Response 1.00 $11,880 $11,880
0007 Licensed Clinician 0.40 $66,560 $26,624
0008 Admin Program Support Staff 0.40 $37,440 $14,976
SALARY TOTAL 6.00 $0 $335,447 $183,505
PAYROLL TAXES:
0030 OASDI $12,871
0031 FICA/MEDICARE $15,549
0032 SUI $5,638
PAYROLL TAX TOTAL $0 $0 $34,058
EMPLOYEE BENEFITS:
0040 Retirement $2,914
0041 Workers Compensation $6,026
0042 Health Insurance (medical, vision, life, dental)$28,769
EMPLOYEE BENEFITS TOTAL $0 $0 $37,709
SALARY & BENEFITS GRAND TOTAL $255,272
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $8,028
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $8,028
Line Item Description (Must be itemized)
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
Budget Categories - Total Proposed Budget
FY 2020-2021
Exhibit C - Page 16 of 47
OPERATING EXPENSES:
1060 Telephone/Cell Phone $4,460
1061 Answering Service $1,275
1062 Postage/Mailing $4,000
1063 Printing/Reproduction $2,000
1064 Publications $0
1065 Legal Notices/Advertising/Outreach $6,500
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies $8,900
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $2,494
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $4,000
1075 Lodging $0
1076 IT Support $4,500
1077 Background Checks $4,950
1078 Uniforms and Badges $3,300
1079 Interpreter Services $2,535
OPERATING EXPENSES TOTAL $48,914
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $3,320
1083 Administrative Overhead $24,097
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $27,417
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant/Volunteer Stipends $7,000
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $7,000
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
Exhibit C - Page 17 of 47
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)$0
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing, Food & Hygiene (SFC 72)$0
2002.2 Client Transportation & Support (SFC 72)$0
2002.3 Education Support (SFC 72)$0
2002.4 Employment Support (SFC 72)$0
2002.5 Respite Care (SFC 72)$0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $0
TOTAL PROGRAM EXPENSES $346,631
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 $0.00 $0
3100 Case Management 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Collateral 0 $0.00 $0
3500 Plan Development 0 $0.00 $0
3600 Assessment 0 $0.00 $0
3700 Rehabilitation 0 $0.00 $0
Estimated Specialty Mental Health Services Billing Totals 0 $0
Estimated % of Clients that are Medi-Cal Beneficiaries 0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $0
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 0.00%$0
State M/Cal Share of Cost % (BH Realignment/EPSDT) 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)$0
4100 Other - (Identify)$0
4200 Other - (Identify)$0
4300 Other - (Identify)$0
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $346,631
5100 Community Services & Supports (CSS) Funds $0
5200 Innovation (INN) Funds $0
5300 Workforce Education & Training (WET) Funds $0
MHSA FUNDS TOTAL $346,631
TOTAL PROGRAM REVENUE $346,631
Exhibit C - Page 18 of 47
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
0001
0002
0003 - 0005
One (1) Director of Center for Grief and Healing
($111,927 Annual Base Salary) x (.2 FTE) = $22,385
Responsible for developing, coordinating, supervising, providing and/or assuring
provision of bereavement services to hospice families and to the community at
large. The Director of the Center for Grief and Healing is responsible for all aspects
of the various bereavement programs and provides supervision to staff and
volunteers involved in the Bereavement Program. In addition, this position will also
provide direct services to clients.
One (1) SOSL Program Coordinator
($68,640 Annual Base Salary) x (1 FTE) = $68,640
Responsible for coordinating grief support services for survivors, community
education, and outreach, to include suicide prevention education. They will also
provide both individual, family and group counseling services. Other duties include
the LOSS team, management of on-call staff and volunteers.
Three (3) On-Call Clinicians
($13,000 Annual Base Salary) x (1 FTE) x 3 Positions = $39,000
Takes calls seven (7) days in a work-period (weekdays, weekends, and holidays)
after the agency’s normal working hours. This wage compensates the employee for
being available for immediate response to Loss Team requests. When a request is
received, the employee will be paid as position 0006 On-Call Response, which is
compensation for call duty. There are a total of 123 hours of on-call shifts per week.
These shifts will be covered by 3 employees with an average on-call schedule of 41
hours each per week. Clinicians are required for this position due to the nature of
the trauma related to suicide death and the impact on survivors, including the risk
of survivors becoming suicidal. It is also the role of the clinician to provide support
and guidance to the suicide loss survivor volunteer and first responders.
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2020-2021
Budget Narrative - Expenses
Exhibit C - Page 19 of 47
0006
0007
0008
0030
0031
0032
0040
SUI
SUI will be paid in a like manner as other employees of Hinds Hospice. ($5,638)
Retirement
Retirement will be paid in a like manner as other employees of Hinds Hospice.
($2,914)
FICA/MEDICARE
FICA/MEDICARE will be paid in a like manner as other employees of Hinds
Hospice. ($15,549)
One (1) After Hour Response Clinician
($30/hr x 288 response hours) x ($45/hr x 72 OT hours) = $11,880
It is estimated that 288 hours will be paid at the base rate of $30/hr and that the
remaining 72 hours will be paid at an overtime of $45/hr. The position provides
direct Active Loss on-scene support to survivors immediately after dispatched.
Clinicians are required for this position due to the nature of the trauma related to
suicide death and the impact on survivors, including the risk of survivors becoming
suicidal. It is also the role of the clinician to provide support and guidance to suicide
loss survivor volunteers and first responders. We estimated that 60% of suicides
will take place outside of normal business hours or approximately 72 per year. Each
response is expected to take 3 hours, which includes travel and volunteer
debriefing. Approximately, one-third of these hours are estimated to be paid at an
over-time rate.
One (1) Licensed Clinician
($66,560 Annual Base Salary) x (.4 FTE) = $26,624
Provides support to grieving individuals, couples, and families. Facilitates support
groups.
One (1) Admin Program Support
($37,440 Annual Base Salary) x (.4 FTE) = $14,976
Responsible for collecting and recording all client data. This individual will assemble
all materials and resources given to families and first responders. This individual
will work directly with the Program Coordinator to facilitate survivor support services
and distribution of satisfaction surveys.
OASDI
OASDI will be paid in a like manner as other employees of Hinds Hospice.
($12,871)
Exhibit C - Page 20 of 47
0041
0042
Facilities/Equipment Expenses – Line Items 1010-1014
1010
Operating Expenses - Line Items 1060-1077
1060
1061
1062
1063
Workers Compensation
Workers Compensation will be paid in a like manner as other employees of Hinds
Hospice. ($6,026)
Health Insurance (medical, vision, life, dental)
Health Insurance will be paid in a like manner as other employees of Hinds
Hospice. ($28,769)
Rent expense is all inclusive and includes space, utilities and housekeeping at a
rate of $1 per square foot per month. The program will occupy approximately 669
square of office space at $1 per foot for 12 months which totals $8,028 annually.
Telephone/Internet/Cell Phone
Phone and Internet - Estimated at $92/mo x 12 months = $1,100
Cell Phones - Estimated at 4 Positions x $70/mo x 12 months = $3,360
Agency issued cellphones are for business use only.
Answering Services
This service documents every call and dispatches to the On-Call Clinician for
response. Used to receive calls after hours, weekends, and holidays. Estimated
@75 calls after hours x $17 = $1,275.
Postage/Mailing
Postage will be used to mail out miscellaneous informational resource packets to
families both local and non-local. Cost is estimated @ $500
Mailings include bereavement mailings, informational resource packets to families,
and invitations to special events. Estimated at $7.50/ person (for 1 year of mailings)
x 350 people + 8 labor hours/week= $3,500
Printing/Reproduction
In-house printing, business cards, flyers, folders and brochures, given to each
family, etc. Costs are estimated @ $2,000
Exhibit C - Page 21 of 47
1065
1069
1072
1074
1076
1077
1078
Staff Training/Registration
This will include the initial training for all volunteers and clinicians on how to
appropriately respond to a LOSS call. This will be facilitated by associates of the
national LOSS Team consultants. After the initial training, this will be used for
ongoing education, trainings and LOSS Team conferences. Cost is estimated @
$4,000.
IT Support
IT Support includes technology support and system security. Cost is estimated @
$4,500 per year.
Background Checks
Background checks are conducted on each LOSS Team members (staff and
volunteers) to ensure safety and protection of the community as the LOSS Team
enters into the homes and workplaces of survivors. Estimated at 30 individuals x
$165/each = $4,950.
Uniforms and Badges
All LOSS team members (staff and volunteers) will wear a designated uniform to
provide professionalism to each on-scene call. Uniforms may consist of collared
shirts and jackets with the official LOSS Team logo. 50 shirts @ $15= $750, 50
jackets @ $40= $2000, 50 nametags @ $5 = $ 250 + set-up and tax $300 =
$3,300.
Staff Mileage/vehicle maintenance
Reimbursement of mileage used to respond to on-scene active and delayed calls.
Estimated 125 responses x 35 miles round trip each x $.57= $2,494.
Legal Notices/Advertising/Outreach
Folders, flyers, envelopes and other materials used to advertise the LOSS team to
both gather volunteers as well as inform 1st responders and other key stakeholders
of the presence of the LOSS team. Cost is estimated @ $2,500)
Outreach activities/events used to connect with the community and survivors such
as a run/walk. Cost is estimated @ $4,000
Program Supplies
Supplies include but are not limited to suicide grief books for children, variety of
resources from American Foundation for Suicide Prevention (AFSP) and Suicide
Awareness Voices of Education (SAVE), and kits to each family (i.e.. Blankets,
journals, etc.). Cost is estimated @ $8,900.
Exhibit C - Page 22 of 47
1079
Financial Services Expenses – Line Items 1080-1085
1082
1083
Special Expenses – Line Items 1090-1092
1090 Consultants/Volunteer Stipends
Volunteers will receive a $50 stipend to attend each LOSS call response. Cost is
estimated based off 140 responses. $50 x $140 = $7,000.
TOTAL PROGRAM EXPENSE:$346,631
Interpreter Services
Interpreter rates = $65/hr (required minimum 2 hours +1 hr travel = 3 hours) = $195
x 13 estimated service calls = $2,535.
Liability Insurance
General liability insurance cost is estimated at $3,320 for the 12 month term.
Administrative Overhead
Indirect costs are those costs of general management that are agency-wide.
General management costs consist of expenditures for administrative activities
necessary for the general operation of Hinds Hospice (e.g., accounting, budgeting,
payroll preparation, personnel management, purchasing, and centralized data
processing). ($24,097)
Exhibit C - Page 23 of 47
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Program Director 0.20 $114,166 $22,833
0002 Program Coordinator 1.00 $70,013 $70,013
0003 On-Call 1.00 $13,260 $13,260
0004 On-Call 1.00 $13,260 $13,260
0005 On-Call 1.00 $13,260 $13,260
0006 After Hour Response 1.00 $12,118 $12,118
0007 Licensed Clinician 0.40 $67,891 $27,156
0008 Admin Program Support Staff 0.40 $38,189 $15,276
SALARY TOTAL 6.00 $0 $605,432 $187,176
PAYROLL TAXES:
0030 OASDI $13,129
0031 FICA/MEDICARE $15,860
0032 SUI $5,665
PAYROLL TAX TOTAL $0 $0 $34,654
EMPLOYEE BENEFITS:
0040 Retirement $2,972
0041 Workers Compensation $6,146
0042 Health Insurance (medical, vision, life, dental)$28,871
EMPLOYEE BENEFITS TOTAL $0 $0 $37,989
SALARY & BENEFITS GRAND TOTAL $259,819
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $8,028
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $8,028
Line Item Description (Must be itemized)
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2021-2022
Budget Categories - Total Proposed Budget
Exhibit C - Page 24 of 47
OPERATING EXPENSES:
1060 Telephone/Cell Phone $4,460
1061 Answering Service $1,275
1062 Postage/Mailing $4,000
1063 Printing/Reproduction $2,000
1064 Publications $0
1065 Legal Notices/Advertising/Outreach $6,500
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies $9,100
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $2,494
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $4,000
1075 Lodging $0
1076 IT Support $4,500
1077 Background Checks $4,950
1078 Uniforms and Badges $3,300
1079 Interpreter Services $2,535
OPERATING EXPENSES TOTAL $49,114
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $3,320
1083 Administrative Overhead $24,579
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $27,899
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant/Volunteer Stipends $7,000
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $7,000
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
Exhibit C - Page 25 of 47
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)$0
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing, Food & Hygiene (SFC 72)$0
2002.2 Client Transportation & Support (SFC 72)$0
2002.3 Education Support (SFC 72)$0
2002.4 Employment Support (SFC 72)$0
2002.5 Respite Care (SFC 72)$0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $0
TOTAL PROGRAM EXPENSES $351,860
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 $0.00 $0
3100 Case Management 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Collateral 0 $0.00 $0
3500 Plan Development 0 $0.00 $0
3600 Assessment 0 $0.00 $0
3700 Rehabilitation 0 $0.00 $0
Estimated Specialty Mental Health Services Billing Totals 0 $0
Estimated % of Clients that are Medi-Cal Beneficiaries 0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $0
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 0.00%$0
State M/Cal Share of Cost % (BH Realignment/EPSDT) 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)$0
4100 Other - (Identify)$0
4200 Other - (Identify)$0
4300 Other - (Identify)$0
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $351,860
5100 Community Services & Supports (CSS) Funds $0
5200 Innovation (INN) Funds $0
5300 Workforce Education & Training (WET) Funds $0
MHSA FUNDS TOTAL $351,860
TOTAL PROGRAM REVENUE $351,860
Exhibit C - Page 26 of 47
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
0001
0002
0003 - 0005
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2021-2022
Budget Narrative - Expenses
One (1) Director of Center for Grief and Healing
($114,166 Annual Base Salary) x (.2 FTE) = $22,833
Responsible for developing, coordinating, supervising, providing and/or assuring
provision of bereavement services to hospice families and to the community at
large. The Director of the Center for Grief and Healing is responsible for all aspects
of the various bereavement programs and provides supervision to staff and
volunteers involved in the Bereavement Program. In addition, this position will also
provide direct services to clients.
One (1) SOSL Program Coordinator
($70,013 Annual Base Salary) x (1 FTE) = $70,013
Responsible for coordinating grief support services for survivors, community
education, and outreach, to include suicide prevention education. They will also
provide both individual, family and group counseling services. Other duties include
the LOSS team, management of on-call staff and volunteers.
Three (3) On-Call Clinicians
($13,260 Annual Base Salary) x (1 FTE) x 3 Positions = $39,780
Takes calls seven (7) days in a work-period (weekdays, weekends, and holidays)
after the agency’s normal working hours. This wage compensates the employee for
being available for immediate response to Loss Team requests. When a request is
received, the employee will be paid as position 0006 On-Call Response, which is
compensation for call duty. There are a total of 123 hours of on-call shifts per week.
These shifts will be covered by 3 employees with an average on-call schedule of 41
hours each per week. Clinicians are required for this position due to the nature of
the trauma related to suicide death and the impact on survivors, including the risk
of survivors becoming suicidal. It is also the role of the clinician to provide support
and guidance to the suicide loss survivor volunteer and first responders.
Exhibit C - Page 27 of 47
0006
0007
0008
0030
0031
0032
0040
FICA/MEDICARE
FICA/MEDICARE will be paid in a like manner as other employees of Hinds
Hospice. ($15,860)
One (1) After Hour Response Clinician
($30.60/hr x 288 response hours) x ($45.90/hr x 72 OT hours) = $12,118
It is estimated that 288 hours will be paid at the base rate of $30/hr and that the
remaining 72 hours will be paid at an overtime of $45/hr. The position provides
direct Active Loss on-scene support to survivors immediately after dispatched.
Clinicians are required for this position due to the nature of the trauma related to
suicide death and the impact on survivors, including the risk of survivors becoming
suicidal. It is also the role of the clinician to provide support and guidance to suicide
loss survivor volunteers and first responders. We estimated that 60% of suicides
will take place outside of normal business hours or approximately 72 per year. Each
response is expected to take 3 hours, which includes travel and volunteer
debriefing. Approximately, one-third of these hours are estimated to be paid at an
over-time rate.
One (1) Licensed Clinician
($67,891 Annual Base Salary) x (.4 FTE) = $27,156
Provides support to grieving individuals, couples, and families. Facilitates support
groups.
One (1) Admin Program Support
($38,189 Annual Base Salary) x (.4 FTE) = $15,276
Responsible for collecting and recording all client data. This individual will assemble
all materials and resources given to families and first responders. This individual
will work directly with the Program Coordinator to facilitate survivor support services
and distribution of satisfaction surveys.
OASDI
OASDI will be paid in a like manner as other employees of Hinds Hospice.
($13,129)
SUI
SUI will be paid in a like manner as other employees of Hinds Hospice. ($5,665)
Retirement
Retirement will be paid in a like manner as other employees of Hinds Hospice.
($2,972)
Exhibit C - Page 28 of 47
0041
0042
Facilities/Equipment Expenses – Line Items 1010-1014
1010
Operating Expenses - Line Items 1060-1077
1060
1061
1062
1063
1065
Workers Compensation
Workers Compensation will be paid in a like manner as other employees of Hinds
Hospice. ($6,146)
Health Insurance (medical, vision, life, dental)
Health Insurance will be paid in a like manner as other employees of Hinds
Hospice. ($28,871)
Rent expense is all inclusive and includes space, utilities and housekeeping at a
rate of $1 per square foot per month. The program will occupy approximately 669
square of office space at $1 per foot for 12 months which totals $8,028 annually.
Telephone/Internet/Cell Phone
Phone and Internet - Estimated at $92/mo x 12 months = $1,100
Cell Phones - Estimated at 4 Positions x $70/mo x 12 months = $3,360
Agency issued cellphones are for business use only.
Answering Services
This service documents every call and dispatches to the On-Call Clinician for
response. Used to receive calls after hours, weekends, and holidays. Estimated
@75 calls after hours x $17 = $1,275.
Postage/Mailing
Postage will be used to mail out miscellaneous informational resource packets to
families both local and non-local. Cost is estimated @ $500
Mailings include bereavement mailings, informational resource packets to families,
and invitations to special events. Estimated at $7.50/ person (for 1 year of mailings)
x 350 people + 8 labor hours/week= $3,500
Printing/Reproduction
In-house printing, business cards, flyers, folders and brochures, given to each
family, etc. Costs are estimated @ $2,000
Legal Notices/Advertising/Outreach
Folders, flyers, envelopes and other materials used to advertise the LOSS team to
both gather volunteers as well as inform 1st responders and other key stakeholders
of the presence of the LOSS team. Cost is estimated @ $2,500)
Outreach activities/events used to connect with the community and survivors such
as a run/walk. Cost is estimated @ $4,000
Exhibit C - Page 29 of 47
1069
1072
1074
1076
1077
1078
1079
Financial Services Expenses – Line Items 1080-1085
1082
Staff Mileage/vehicle maintenance
Reimbursement of mileage used to respond to on-scene active and delayed calls.
Estimated 125 responses x 35 miles round trip each x $.57= $2,494.
Program Supplies
Supplies include but are not limited to suicide grief books for children, variety of
resources from American Foundation for Suicide Prevention (AFSP) and Suicide
Awareness Voices of Education (SAVE), and kits to each family (i.e.. Blankets,
journals, etc.). Cost is estimated @ $9,100.
Staff Training/Registration
This will include the initial training for all volunteers and clinicians on how to
appropriately respond to a LOSS call. This will be facilitated by associates of the
national LOSS Team consultants. After the initial training, this will be used for
ongoing education, trainings and LOSS Team conferences. Cost is estimated @
$4,000.
IT Support
IT Support includes technology support and system security. Cost is estimated @
$4,500 per year.
Background Checks
Background checks are conducted on each LOSS Team members (staff and
volunteers) to ensure safety and protection of the community as the LOSS Team
enters into the homes and workplaces of survivors. Estimated at 30 individuals x
$165/each = $4,950.
Uniforms and Badges
All LOSS team members (staff and volunteers) will wear a designated uniform to
provide professionalism to each on-scene call. Uniforms may consist of collared
shirts and jackets with the official LOSS Team logo. 50 shirts @ $15= $750, 50
jackets @ $40= $2000, 50 nametags @ $5 = $ 250 + set-up and tax $300 =
$3,300.
Interpreter Services
Interpreter rates = $65/hr (required minimum 2 hours +1 hr travel = 3 hours) = $195
x 13 estimated service calls = $2,535.
Liability Insurance
General liability insurance cost is estimated at $3,320 for the 12 month term.
Exhibit C - Page 30 of 47
1083
Special Expenses – Line Items 1090-1092
1090 Consultants/Volunteer Stipends
Volunteers will receive a $50 stipend to attend each LOSS call response. Cost is
estimated based off 140 responses. $50 x $140 = $7,000.
TOTAL PROGRAM EXPENSE:$351,860
Administrative Overhead
Indirect costs are those costs of general management that are agency-wide.
General management costs consist of expenditures for administrative activities
necessary for the general operation of Hinds Hospice (e.g., accounting, budgeting,
payroll preparation, personnel management, purchasing, and centralized data
processing). ($24,579)
Exhibit C - Page 31 of 47
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Program Director 0.20 $116,449 $23,290
0002 Program Coordinator 1.00 $71,413 $71,413
0003 On-Call 1.00 $13,525 $13,525
0004 On-Call 1.00 $13,525 $13,525
0005 On-Call 1.00 $13,525 $13,525
0006 After Hour Response 1.00 $12,360 $12,360
0007 Licensed Clinician 0.40 $69,249 $27,700
0008 Admin Program Support Staff 0.40 $38,953 $15,581
SALARY TOTAL 6.00 $0 $348,999 $190,919
PAYROLL TAXES:
0030 OASDI $13,391
0031 FICA/MEDICARE $16,178
0032 SUI $5,693
PAYROLL TAX TOTAL $0 $0 $35,262
EMPLOYEE BENEFITS:
0040 Retirement $3,032
0041 Workers Compensation $6,269
0042 Health Insurance (medical, vision, life, dental)$28,975
EMPLOYEE BENEFITS TOTAL $0 $0 $38,276
SALARY & BENEFITS GRAND TOTAL $264,457
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $8,028
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $8,028
Line Item Description (Must be itemized)
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2022-2023
Budget Categories - Total Proposed Budget
Exhibit C - Page 32 of 47
OPERATING EXPENSES:
1060 Telephone/Cell Phone $4,460
1061 Answering Service $1,275
1062 Postage/Mailing $4,000
1063 Printing/Reproduction $2,000
1064 Publications $0
1065 Legal Notices/Advertising/Outreach $6,500
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies $8,100
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $2,494
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $3,500
1075 Lodging $0
1076 IT Support $4,500
1077 Background Checks $4,950
1078 Uniforms and Badges $3,300
1079 Interpreter Services $2,535
OPERATING EXPENSES TOTAL $47,614
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $3,320
1083 Administrative Overhead $25,071
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $28,391
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant/Volunteer Stipends $7,000
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $7,000
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
Exhibit C - Page 33 of 47
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)$0
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing, Food & Hygiene (SFC 72)$0
2002.2 Client Transportation & Support (SFC 72)$0
2002.3 Education Support (SFC 72)$0
2002.4 Employment Support (SFC 72)$0
2002.5 Respite Care (SFC 72)$0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $0
TOTAL PROGRAM EXPENSES $355,489
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 $0.00 $0
3100 Case Management 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Collateral 0 $0.00 $0
3500 Plan Development 0 $0.00 $0
3600 Assessment 0 $0.00 $0
3700 Rehabilitation 0 $0.00 $0
Estimated Specialty Mental Health Services Billing Totals 0 $0
Estimated % of Clients that are Medi-Cal Beneficiaries 0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $0
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 0.00%$0
State M/Cal Share of Cost % (BH Realignment/EPSDT) 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)$0
4100 Other - (Identify)$0
4200 Other - (Identify)$0
4300 Other - (Identify)$0
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $355,489
5100 Community Services & Supports (CSS) Funds $0
5200 Innovation (INN) Funds $0
5300 Workforce Education & Training (WET) Funds $0
MHSA FUNDS TOTAL $355,489
TOTAL PROGRAM REVENUE $355,489
Exhibit C - Page 34 of 47
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
0001
0002
0003 - 0005
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2022-2023
Budget Narrative - Expenses
One (1) Director of Center for Grief and Healing
($116,449 Annual Base Salary) x (.2 FTE) = $23,290
Responsible for developing, coordinating, supervising, providing and/or assuring
provision of bereavement services to hospice families and to the community at
large. The Director of the Center for Grief and Healing is responsible for all aspects
of the various bereavement programs and provides supervision to staff and
volunteers involved in the Bereavement Program. In addition, this position will also
provide direct services to clients.
One (1) SOSL Program Coordinator
($71,413 Annual Base Salary) x (1 FTE) = $71,413
Responsible for coordinating grief support services for survivors, community
education, and outreach, to include suicide prevention education. They will also
provide both individual, family and group counseling services. Other duties include
the LOSS team, management of on-call staff and volunteers.
Three (3) On-Call Clinicians
($13,525 Annual Base Salary) x (1 FTE) x 3 Positions = $40,575
Takes calls seven (7) days in a work-period (weekdays, weekends, and holidays)
after the agency’s normal working hours. This wage compensates the employee for
being available for immediate response to Loss Team requests. When a request is
received, the employee will be paid as position 0006 On-Call Response, which is
compensation for call duty. There are a total of 123 hours of on-call shifts per week.
These shifts will be covered by 3 employees with an average on-call schedule of 41
hours each per week. Clinicians are required for this position due to the nature of
the trauma related to suicide death and the impact on survivors, including the risk
of survivors becoming suicidal. It is also the role of the clinician to provide support
and guidance to the suicide loss survivor volunteer and first responders.
Exhibit C - Page 35 of 47
0006
0007
0008
0030
0031
0032
0040
FICA/MEDICARE
FICA/MEDICARE will be paid in a like manner as other employees of Hinds
Hospice. ($16,178)
One (1) After Hour Response Clinician
($31.21/hr x 288 response hours) x ($46.82/hr x 72 OT hours) = $12,360
It is estimated that 288 hours will be paid at the base rate of $30/hr and that the
remaining 72 hours will be paid at an overtime of $45/hr. The position provides
direct Active Loss on-scene support to survivors immediately after dispatched.
Clinicians are required for this position due to the nature of the trauma related to
suicide death and the impact on survivors, including the risk of survivors becoming
suicidal. It is also the role of the clinician to provide support and guidance to suicide
loss survivor volunteers and first responders. We estimated that 60% of suicides
will take place outside of normal business hours or approximately 72 per year. Each
response is expected to take 3 hours, which includes travel and volunteer
debriefing. Approximately, one-third of these hours are estimated to be paid at an
over-time rate.
One (1) Licensed Clinician
($69,249 Annual Base Salary) x (.4 FTE) = $27,700
Provides support to grieving individuals, couples, and families. Facilitates support
groups.
One (1) Admin Program Support
($38,953 Annual Base Salary) x (.4 FTE) = $15,581
Responsible for collecting and recording all client data. This individual will assemble
all materials and resources given to families and first responders. This individual
will work directly with the Program Coordinator to facilitate survivor support services
and distribution of satisfaction surveys.
OASDI
OASDI will be paid in a like manner as other employees of Hinds Hospice.
($13,391)
SUI
SUI will be paid in a like manner as other employees of Hinds Hospice. ($5,693)
Retirement
Retirement will be paid in a like manner as other employees of Hinds Hospice.
($3,032)
Exhibit C - Page 36 of 47
0041
0042
Facilities/Equipment Expenses – Line Items 1010-1014
1010
Operating Expenses - Line Items 1060-1077
1060
1061
1062
1063
Workers Compensation
Workers Compensation will be paid in a like manner as other employees of Hinds
Hospice. ($6,269)
Health Insurance (medical, vision, life, dental)
Health Insurance will be paid in a like manner as other employees of Hinds
Hospice. ($28,975)
Rent expense is all inclusive and includes space, utilities and housekeeping at a
rate of $1 per square foot per month. The program will occupy approximately 669
square of office space at $1 per foot for 12 months which totals $8,028 annually.
Telephone/Internet/Cell Phone
Phone and Internet - Estimated at $92/mo x 12 months = $1,100
Cell Phones - Estimated at 4 Positions x $70/mo x 12 months = $3,360
Agency issued cellphones are for business use only.
Answering Services
This service documents every call and dispatches to the On-Call Clinician for
response. Used to receive calls after hours, weekends, and holidays. Estimated
@75 calls after hours x $17 = $1,275.
Postage/Mailing
Postage will be used to mail out miscellaneous informational resource packets to
families both local and non-local. Cost is estimated @ $500
Mailings include bereavement mailings, informational resource packets to families,
and invitations to special events. Estimated at $7.50/ person (for 1 year of mailings)
x 350 people + 8 labor hours/week= $3,500
Printing/Reproduction
In-house printing, business cards, flyers, folders and brochures, given to each
family, etc. Costs are estimated @ $2,000
Exhibit C - Page 37 of 47
1065
1069
1072
1074
1076
1077
1078
Staff Mileage/vehicle maintenance
Reimbursement of mileage used to respond to on-scene active and delayed calls.
Estimated 125 responses x 35 miles round trip each x $.57= $2,494.
Legal Notices/Advertising/Outreach
Folders, flyers, envelopes and other materials used to advertise the LOSS team to
both gather volunteers as well as inform 1st responders and other key stakeholders
of the presence of the LOSS team. Cost is estimated @ $2,500)
Outreach activities/events used to connect with the community and survivors such
as a run/walk. Cost is estimated @ $4,000
Program Supplies
Supplies include but are not limited to suicide grief books for children, variety of
resources from American Foundation for Suicide Prevention (AFSP) and Suicide
Awareness Voices of Education (SAVE), and kits to each family (i.e.. Blankets,
journals, etc.). Cost is estimated @ $8,100.
Staff Training/Registration
This will include the initial training for all volunteers and clinicians on how to
appropriately respond to a LOSS call. This will be facilitated by associates of the
national LOSS Team consultants. After the initial training, this will be used for
ongoing education, trainings and LOSS Team conferences. Cost is estimated @
$3,500.
IT Support
IT Support includes technology support and system security. Cost is estimated @
$4,500 per year.
Background Checks
Background checks are conducted on each LOSS Team members (staff and
volunteers) to ensure safety and protection of the community as the LOSS Team
enters into the homes and workplaces of survivors. Estimated at 30 individuals x
$165/each = $4,950.
Uniforms and Badges
All LOSS team members (staff and volunteers) will wear a designated uniform to
provide professionalism to each on-scene call. Uniforms may consist of collared
shirts and jackets with the official LOSS Team logo. 50 shirts @ $15= $750, 50
jackets @ $40= $2000, 50 nametags @ $5 = $ 250 + set-up and tax $300 =
$3,300.
Exhibit C - Page 38 of 47
1079
Financial Services Expenses – Line Items 1080-1085
1082
1083
Special Expenses – Line Items 1090-1092
1090 Consultants/Volunteer Stipends
Volunteers will receive a $50 stipend to attend each LOSS call response. Cost is
estimated based off 140 responses. $50 x $140 = $7,000.
TOTAL PROGRAM EXPENSE:$355,489
Interpreter Services
Interpreter rates = $65/hr (required minimum 2 hours +1 hr travel = 3 hours) = $195
x 13 estimated service calls = $2,535.
Liability Insurance
General liability insurance cost is estimated at $3,320 for the 12 month term.
Administrative Overhead
Indirect costs are those costs of general management that are agency-wide.
General management costs consist of expenditures for administrative activities
necessary for the general operation of Hinds Hospice (e.g., accounting, budgeting,
payroll preparation, personnel management, purchasing, and centralized data
processing). ($25,071)
Exhibit C - Page 39 of 47
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Program Director 0.20 $118,778 $23,756
0002 Program Coordinator 1.00 $72,841 $72,841
0003 On-Call 1.00 $13,796 $13,796
0004 On-Call 1.00 $13,796 $13,796
0005 On-Call 1.00 $13,796 $13,796
0006 After Hour Response 1.00 $12,607 $12,607
0007 Licensed Clinician 0.40 $70,634 $28,254
0008 Admin Program Support Staff 0.40 $39,732 $15,893
SALARY TOTAL 6.00 $0 $355,980 $194,738
PAYROLL TAXES:
0030 OASDI $13,659
0031 FICA/MEDICARE $16,501
0032 SUI $5,721
PAYROLL TAX TOTAL $0 $0 $35,881
EMPLOYEE BENEFITS:
0040 Retirement $3,093
0041 Workers Compensation $6,395
0042 Health Insurance (medical, vision, life, dental)$29,082
EMPLOYEE BENEFITS TOTAL $0 $0 $38,570
SALARY & BENEFITS GRAND TOTAL $269,189
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $8,028
1011 Rent/Lease Equipment $0
1012 Utilities $0
1013 Building Maintenance $0
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $8,028
Line Item Description (Must be itemized)
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2023-2024
Budget Categories - Total Proposed Budget
Exhibit C - Page 40 of 47
OPERATING EXPENSES:
1060 Telephone/Cell Phone $4,460
1061 Answering Service $1,275
1062 Postage/Mailing $4,000
1063 Printing/Reproduction $2,000
1064 Publications $0
1065 Legal Notices/Advertising/Outreach $6,500
1066 Office Supplies & Equipment $0
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies $8,500
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $2,494
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $3,000
1075 Lodging $0
1076 IT Support $4,500
1077 Background Checks $4,950
1078 Uniforms and Badges $3,300
1079 Interpreter Services $2,535
OPERATING EXPENSES TOTAL $47,514
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $3,320
1083 Administrative Overhead $25,571
1084 Payroll Services $0
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $28,891
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant/Volunteer Stipends $7,000
1091 Translation Services $0
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $7,000
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other - (Identify)$0
1193 Other - (Identify)$0
FIXED ASSETS TOTAL $0
Exhibit C - Page 41 of 47
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)$0
2001 Client Housing Operating Expenditures (SFC 71)$0
2002.1 Clothing, Food & Hygiene (SFC 72)$0
2002.2 Client Transportation & Support (SFC 72)$0
2002.3 Education Support (SFC 72)$0
2002.4 Employment Support (SFC 72)$0
2002.5 Respite Care (SFC 72)$0
2002.6 Household Items $0
2002.7 Utility Vouchers (SFC 72)$0
2002.8 Child Care (SFC 72)$0
NON MEDI-CAL CLIENT SUPPORT TOTAL $0
TOTAL PROGRAM EXPENSES $360,622
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 $0.00 $0
3100 Case Management 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Collateral 0 $0.00 $0
3500 Plan Development 0 $0.00 $0
3600 Assessment 0 $0.00 $0
3700 Rehabilitation 0 $0.00 $0
Estimated Specialty Mental Health Services Billing Totals 0 $0
Estimated % of Clients that are Medi-Cal Beneficiaries 0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $0
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 0.00%$0
State M/Cal Share of Cost % (BH Realignment/EPSDT) 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)$0
4100 Other - (Identify)$0
4200 Other - (Identify)$0
4300 Other - (Identify)$0
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $360,622
5100 Community Services & Supports (CSS) Funds $0
5200 Innovation (INN) Funds $0
5300 Workforce Education & Training (WET) Funds $0
MHSA FUNDS TOTAL $360,622
TOTAL PROGRAM REVENUE $360,622
Exhibit C - Page 42 of 47
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
0001
0002
0003 - 0005
Budget Summary
Local Outreach to Suicide Survivors (LOSS) Team
Hinds Hospice
FY 2023-2024
Budget Narrative - Expenses
One (1) Director of Center for Grief and Healing
($118,778 Annual Base Salary) x (.2 FTE) = $23,756
Responsible for developing, coordinating, supervising, providing and/or assuring
provision of bereavement services to hospice families and to the community at
large. The Director of the Center for Grief and Healing is responsible for all aspects
of the various bereavement programs and provides supervision to staff and
volunteers involved in the Bereavement Program. In addition, this position will also
provide direct services to clients.
One (1) SOSL Program Coordinator
($72,841 Annual Base Salary) x (1 FTE) = $72,841
Responsible for coordinating grief support services for survivors, community
education, and outreach, to include suicide prevention education. They will also
provide both individual, family and group counseling services. Other duties include
the LOSS team, management of on-call staff and volunteers.
Three (3) On-Call Clinicians
($13,796 Annual Base Salary) x (1 FTE) x 3 Positions = $41,388
Takes calls seven (7) days in a work-period (weekdays, weekends, and holidays)
after the agency’s normal working hours. This wage compensates the employee for
being available for immediate response to Loss Team requests. When a request is
received, the employee will be paid as position 0006 On-Call Response, which is
compensation for call duty. There are a total of 123 hours of on-call shifts per week.
These shifts will be covered by 3 employees with an average on-call schedule of 41
hours each per week. Clinicians are required for this position due to the nature of
the trauma related to suicide death and the impact on survivors, including the risk
of survivors becoming suicidal. It is also the role of the clinician to provide support
and guidance to the suicide loss survivor volunteer and first responders.
Exhibit C - Page 43 of 47
0006
0007
0008
0030
0031
0032
0040
FICA/MEDICARE
FICA/MEDICARE will be paid in a like manner as other employees of Hinds
Hospice. ($16,501)
One (1) After Hour Response Clinician
($31.83/hr x 288 response hours) x ($47.76/hr x 72 OT hours) = $12,607
It is estimated that 288 hours will be paid at the base rate of $30/hr and that the
remaining 72 hours will be paid at an overtime of $45/hr. The position provides
direct Active Loss on-scene support to survivors immediately after dispatched.
Clinicians are required for this position due to the nature of the trauma related to
suicide death and the impact on survivors, including the risk of survivors becoming
suicidal. It is also the role of the clinician to provide support and guidance to suicide
loss survivor volunteers and first responders. We estimated that 60% of suicides
will take place outside of normal business hours or approximately 72 per year. Each
response is expected to take 3 hours, which includes travel and volunteer
debriefing. Approximately, one-third of these hours are estimated to be paid at an
over-time rate.
One (1) Licensed Clinician
($70,634 Annual Base Salary) x (.4 FTE) = $28,254
Provides support to grieving individuals, couples, and families. Facilitates support
groups.
One (1) Admin Program Support
($39,732 Annual Base Salary) x (.4 FTE) = $15,893
Responsible for collecting and recording all client data. This individual will assemble
all materials and resources given to families and first responders. This individual
will work directly with the Program Coordinator to facilitate survivor support services
and distribution of satisfaction surveys.
OASDI
OASDI will be paid in a like manner as other employees of Hinds Hospice.
($13,659)
SUI
SUI will be paid in a like manner as other employees of Hinds Hospice. ($5,721)
Retirement
Retirement will be paid in a like manner as other employees of Hinds Hospice.
($3,093)
Exhibit C - Page 44 of 47
0041
0042
Facilities/Equipment Expenses – Line Items 1010-1014
1010
Operating Expenses - Line Items 1060-1077
1060
1061
1062
1063
1065
Workers Compensation
Workers Compensation will be paid in a like manner as other employees of Hinds
Hospice. ($6,395)
Health Insurance (medical, vision, life, dental)
Health Insurance will be paid in a like manner as other employees of Hinds
Hospice. ($29,082)
Rent expense is all inclusive and includes space, utilities and housekeeping at a
rate of $1 per square foot per month. The program will occupy approximately 669
square of office space at $1 per foot for 12 months which totals $8,028 annually.
Telephone/Internet/Cell Phone
Phone and Internet - Estimated at $92/mo x 12 months = $1,100
Cell Phones - Estimated at 4 Positions x $70/mo x 12 months = $3,360
Agency issued cellphones are for business use only.
Answering Services
This service documents every call and dispatches to the On-Call Clinician for
response. Used to receive calls after hours, weekends, and holidays. Estimated
@75 calls after hours x $17 = $1,275.
Postage/Mailing
Postage will be used to mail out miscellaneous informational resource packets to
families both local and non-local. Cost is estimated @ $500
Mailings include bereavement mailings, informational resource packets to families,
and invitations to special events. Estimated at $7.50/ person (for 1 year of mailings)
x 350 people + 8 labor hours/week= $3,500
Printing/Reproduction
In-house printing, business cards, flyers, folders and brochures, given to each
family, etc. Costs are estimated @ $2,000
Legal Notices/Advertising/Outreach
Folders, flyers, envelopes and other materials used to advertise the LOSS team to
both gather volunteers as well as inform 1st responders and other key stakeholders
of the presence of the LOSS team. Cost is estimated @ $2,500)
Outreach activities/events used to connect with the community and survivors such
as a run/walk. Cost is estimated @ $4,000
Exhibit C - Page 45 of 47
1069
1072
1074
1076
1077
1078
1079
Financial Services Expenses – Line Items 1080-1085
1082
Staff Mileage/vehicle maintenance
Reimbursement of mileage used to respond to on-scene active and delayed calls.
Estimated 125 responses x 35 miles round trip each x $.57= $2,494.
Program Supplies
Supplies include but are not limited to suicide grief books for children, variety of
resources from American Foundation for Suicide Prevention (AFSP) and Suicide
Awareness Voices of Education (SAVE), and kits to each family (i.e.. Blankets,
journals, etc.). Cost is estimated @ $8,500.
Staff Training/Registration
This will include the initial training for all volunteers and clinicians on how to
appropriately respond to a LOSS call. This will be facilitated by associates of the
national LOSS Team consultants. After the initial training, this will be used for
ongoing education, trainings and LOSS Team conferences. Cost is estimated @
$3,000.
IT Support
IT Support includes technology support and system security. Cost is estimated @
$4,500 per year.
Background Checks
Background checks are conducted on each LOSS Team members (staff and
volunteers) to ensure safety and protection of the community as the LOSS Team
enters into the homes and workplaces of survivors. Estimated at 30 individuals x
$165/each = $4,950.
Uniforms and Badges
All LOSS team members (staff and volunteers) will wear a designated uniform to
provide professionalism to each on-scene call. Uniforms may consist of collared
shirts and jackets with the official LOSS Team logo. 50 shirts @ $15= $750, 50
jackets @ $40= $2000, 50 nametags @ $5 = $ 250 + set-up and tax $300 =
$3,300.
Interpreter Services
Interpreter rates = $65/hr (required minimum 2 hours +1 hr travel = 3 hours) = $195
x 13 estimated service calls = $2,535.
Liability Insurance
General liability insurance cost is estimated at $3,320 for the 12 month term.
Exhibit C - Page 46 of 47
1083
Special Expenses – Line Items 1090-1092
1090 Consultants/Volunteer Stipends
Volunteers will receive a $50 stipend to attend each LOSS call response. Cost is
estimated based off 140 responses. $50 x $140 = $7,000.
TOTAL PROGRAM EXPENSE:$360,622
Administrative Overhead
Indirect costs are those costs of general management that are agency-wide.
General management costs consist of expenditures for administrative activities
necessary for the general operation of Hinds Hospice (e.g., accounting, budgeting,
payroll preparation, personnel management, purchasing, and centralized data
processing). ($25,071)
Exhibit C - Page 47 of 47
Section: Mental Health
Effective Date: 05/30/2017 Revised Date: 05/30/2017
Policy Title: Performance Outcome Measures
Approved by: Dawan Utecht (Director of Behavioral Health), Francisco Escobedo (Sr. Staff Analyst - QA), Kannika
Toonnachat (Division Manager - Technology and Quality Management)
1 | P a g e
MISSION STATEMENT
The Department of Behavioral Health is dedicated to supporting the wellness of individuals, families and communities in Fresno County who are affected by, or are at risk
of, mental illness and/or substance use disorders through cultivation of strengths toward promoting recovery in the least restrictive environment.
Template Review Date 3/28/16
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.7
POLICY: It is the policy of Fresno County Department of Behavioral Health and the
Fresno County Mental Health Plan (FCMHP) to ensure procedures for
developing performance measures which accurately reflect vital areas of
performance and provide for systematic, ongoing collection and analysis
of valid and reliable data. Data collection is not intended to be an
additional task for FCMHP programs/providers but rather embedded within
the various non-treatment, treatment and clinical documentation.
PURPOSE:To determine the effectiveness and efficiency of services provided by
measuring performance outcomes/results achieved by the persons served
during service delivery or following service completion, delivery of service,
and of the individuals’ satisfaction. This is a vital management tool used to
clarify goals, document the efforts toward achieving those goals, and thus
measure the benefit the service delivery to the persons served.
Performance measurement selection is part of the planning and
developing process design of the program. Performance measurement is
the ongoing monitoring and reporting of progress towards pre-established
objectives/goals.
REFERENCE: California Code of Regulations, Title 9, Chapter 11, Section
1810.380(a)(1): State Oversight
DHCS Service, Administrative and Operational Requirements
Mental Health Services Act (MHSA), California Code of Regulations, Title
9, Section 3320, 3200.050, and 3200.120
Commission on Accreditation of Rehabilitation Facilities (CARF)
DEFINITIONS:
1.Indicator: Qualitative or quantitative measure(s) that tell if the outcomes have been
accomplished. Indicators evaluate key performance in relation to objectives. It indicates
what the program is accomplishing and if the anticipated results are being achieved.
Exhibit D - Page 1 of 6
2 | P a g e
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.7
Policy Title: Performance Outcome Measures
Section: Mental Health Effective Date: 05/30/2017
2.Intervention: A systematic plan of action consciously adapted in an attempt to address
and reduce the causes of failure or need to improve upon system.
3.Fresno County Mental Health Plan (FCMHP): Fresno County’s contract with the State
Department of Health and Human Services that allows for the provision of specialty
mental health services. Services may be delivered by county-operated programs,
contracted organizational, or group providers.
4.Objective (Goal): Intended results or the impact of learning, programs, or activities.
5.Outcomes: Specific results or changes achieved as a consequence of the program or
intervention. Outcomes are connected to the objectives/goals identified by the program
or intervention.
PROCEDURE:
I. Each FCMHP program/provider shall engage in measurement of outcomes in order
to generate reliable and valid data on the effectiveness and efficiency of programs or
interventions. Programs/providers will establish/select objectives (goals), decide on
a methodology and timeline for the collection of data, and use an appropriate data
collection tool. This occurs during the program planning and development process.
Outcomes should be in alignment with the program/provider goals.
II.Outcomes should be measureable, obtainable, clear, accurately reflect the expected
result, and include specific time frames. Once the measures have been selected, it
is necessary to design a way to gather the information. For each service delivery
performance indicator, FCMHP program/provider shall determine: to whom the
indicator will be applied; who is responsible for collecting the data; the tool from
which data will be collected; and a performance target based on an industry
benchmark, or a benchmark set by the program/provider.
III. Performance measures are subject to review and approval by FCMHP
Administration.
IV. Performance measurement is the ongoing monitoring and reporting of progress
towards pre-established objectives/goals. Annually, each FCMHP program/provider
must measure service delivery performance in each of the areas/domains listed
below. Dependent on the program/provider service deliverables, exceptions must be
approved by the FCMHP Administration.
Exhibit D - Page 2 of 6
3 | P a g e
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.7
Policy Title: Performance Outcome Measures
Section: Mental Health Effective Date: 05/30/2017
a. Effectiveness of services – How well programs performed and the results
achieved. Effectiveness measures address the quality of care through
measuring change over time. Examples include but are not limited to: reduction
of hospitalization, reduction of symptoms, employment and housing status, and
reduction of recidivism rate and incidence of relapse.
b. Efficiency of services – The relationship between the outcomes and the
resources used. Examples include but are not limited to: service delivery cost per
service unit, length of stay, and direct service hours of clinical and medical staff.
c. Services access – Changes or improvements in the program/provider’s capacity
and timeliness to provide services to those who request them. Examples include
but are not limited to: wait/length of time from first request/referral to first service
or subsequent appointment, convenience of service hours and locations, number
of clients served by program capacity, and no-show and cancellation rates.
d. Satisfaction and feedback from persons served and stakeholders– Changes or
increased positive/negative feedback regarding the experiences of the persons
served and others (families, referral sources, payors/guarantors, etc.).
Satisfaction measures are usually oriented toward clients, family members,
personnel, the community, and funding sources. Examples include but are not
limited to: did the organization/program focus on the recovery of the person
served, were grievances or concerns addressed, overall feelings of satisfaction,
and satisfaction with physical facilities, fees, access, service effectiveness, and
efficiency.
V. Each FCMHP program/provider shall use the following templates to document the
defined goals, intervention(s), specific indicators, and outcomes.
1. FCMHP Outcome Report template (see Attachment A)
2. FCMHP Outcome Analysis template (see Attachment C)
Exhibit D - Page 3 of 6
FRESNO COUNTY MENTAL HEALTH PLAN OUTCOMES REPORT- Attachment A
Revised May 2018
PROGRAM INFORMATION:
Program Title: Click here to enter text. Provider: Click here to enter text.
Program Description: Click here to enter text. MHP Work Plan: Choose an item.
Choose an item.
Choose an item.
Age Group Served 1: ADULT Dates Of Operation: Click here to enter text.
Age Group Served 2: Choose an item. Reporting Period: Choose an item.
Funding Source 1: Choose an item. Funding Source 3: Choose an item.
Funding Source 2: Choose an item. Other Funding: Click here to enter text.
FISCAL INFORMATION:
Program Budget Amount: Click here to enter text. Program Actual Amount: 0
Number of Unique Clients Served During Time Period: 0
Number of Services Rendered During Time Period: Click here to enter text.
Actual Cost Per Client: 0
CONTRACT INFORMATION:
Program Type: Type of Program:
Contract Term: Click here to enter text. For Other: Click here to enter text.
Renewal Date: Click here to enter text.
Level of Care Information Age 18 & Over: Choose an item.
Level of Care Information Age 0- 17: Choose an item.
TARGET POPULATION INFORMATION:
Target Population: Click here to enter text.
Exhibit D - Page 4 of 6
FRESNO COUNTY MENTAL HEALTH PLAN OUTCOMES REPORT- Attachment A
Revised May 2018
CORE CONCEPTS:
•Community collaboration: individuals, families, agencies, and businesses work together to accomplish a shared vision.
•Cultural competence: adopting behaviors, attitudes and policies that enable providers to work effectively in cross-cultural situations.
•Individual/Family-Driven, Wellness/Recovery/Resiliency-Focused Services: adult clients and families of children and youth identify needs and preferences that result in
the most effective services and supports.•Access to underserved communities: Historically unserved and underserved communities are those groups that either have documented low levels of access and/or use of
mental health services, face barriers to participation in the policy making process in public mental health, have low rates of insurance coverage for mental health care, and/or
have been identified as priorities for mental health services.
•Integrated service experiences: services for clients and families are seamless. Clients and families do not have to negotiate with multiple agencies and funding sources to
meet their needs.
Please select core concepts embedded in services/ program:
(May select more than one) Please describe how the selected concept (s) embedded :
Choose an item. Click here to enter text.
Choose an item.
Choose an item.
Choose an item.
PROGRAM OUTCOME & GOALS
-Must include each of these areas/domains: (1) Effectiveness, (2) Efficiency, (3) Access, (4) Satisfaction & Feedback Of Persons Served & Stakeholder-Include the following components for documenting each goal: (1) Indicator, (2) Who Applied, (3) Time of Measure, (4) Data Source, (5) Target Goal Expectancy
Click here to enter text.
DEPARTMENT RECOMMENDATION(S):
Click here to enter text.
Exhibit D - Page 5 of 6
FRESNO COUNTY MENTAL HEALTH PLAN
Outcomes Analysis Attachment C
Name of Program: Click here to enter text.
What is the Program/Contract Goals? Click here to enter text.
Program Type: ____________ Type of Program: Other, please specify below
Other: Click here to enter text.
CLINICAL INFORMATION:
Does the Program Utilize Any of the Following? (May select more than one)
Evidence Informed Practice Best Practice Evidence Based Practice
Other: Click here to enter text.
Please Describe: Click here to enter text.
OUTCOMES
What Outcome Measures Are Being Used? Click here to enter text.
What Outcome Measures/Functional Variables Could Be Added to Better Explain the Program’s
Effectiveness? Click here to enter text.
Describe the Program’s analysis (i.e. have the program/contract goals been met? Number served,
waiting list, wait times, budget to volume, etc.): Click here to enter text.
What Barriers Prevent the Program from Achieving Better Outcomes? Click here to enter text.
What Changes to the Program Would You Recommend to Improve the outcomes ? Click here to
enter text.
For Committee Use Only:
Recommendations: do include a conclusion and a to-do list with action items
Click here to enter text.
Exhibit D - Page 6 of 6
Exhibit E - Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business
and Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with all
State of California and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements at 42, Code
of Federal Regulations sections 2.1 et seq; California Welfare and Institutions
Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the
California Health and Safety Code; Title 22, California Code of Regulations,
section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates
of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment.
Exhibit E - Page 2 of 6
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all further
funds, until CONTRACTOR can show clear and convincing evidence to
the satisfaction of COUNTY that funds provided under this Agreement
were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: CONTRACTOR has, unless exempted,
complied with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f)
and CCR, Title 2, Section 111 02) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: CONTRACTOR will comply
with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-
free workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is prohibited and
specifying actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free
workplace;
3) any available counseling, rehabilitation and employee assistance
programs; and,
4) penalties that may be imposed upon employees for drug abuse
violations.
c. Every employee who works on this Agreement will:
1) receive a copy of the company's drug -free workplace policy
statement; and,
2) agree to abide by the terms of the company's statement as a
condition of employment on this Agreement.
Exhibit E - Page 3 of 6
Failure to comply with these requirements may result in suspension of payments under
this Agreement or termination of this Agreement or both and CONTRACTOR may be
ineligible for award of any future State agreements if the department determines that any
of the following has occurred: the CONTRACTOR has made false certification, or
violated the certification by failing to carry out the requirements as noted above. (Gov.
Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: CONTRACTOR
certifies that no more than one (1) final unappealable finding of contempt of court by a
Federal court has been issued against CONTRACTOR within the immediately preceding
two (2) year period because of CONTRACTOR’s failure to comply with an order of a
Federal court, which orders CONTRACTOR to comply with an order of the National
Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: CONTRACTOR hereby certifies that CONTRACTOR will comply with
the requirements of Section 6072 of the Business and Professions Code, effective
January 1, 2003.
CONTRACTOR agrees to make a good faith effort to provide a minimum number of
hours of pro bono legal services during each year of the contract equal to the lessor of
30 multiplied by the number of full time attorneys in the firm’s offices in the State, with
the number of hours prorated on an actual day basis for any contract period of less than
a full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: CONTRACTOR hereby declares that it is not
an expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All CONTRACTORS contracting for the procurement or laundering of
apparel, garments or corresponding accessories, or the procurement of equipment,
materials, or supplies, other than procurement related to a public works contract, declare
under penalty of perjury that no apparel, garments or corresponding accessories,
equipment, materials, or supplies furnished to the state pursuant to the contract have
been laundered or produced in whole or in part by sweatshop labor, forced labor, convict
labor, indentured labor under penal sanction, abusive forms of child labor or exploitation
of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor,
convict labor, indentured labor under penal sanction, abusive forms of child labor or
exploitation of children in sweatshop labor. CONTRACTOR further declares under
penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the
California Department of Industrial Relations website located at www.dir.ca.gov, and
Public Contract Code Section 6108.
Exhibit E - Page 4 of 6
b. CONTRACTOR agrees to cooperate fully in providing reasonable access
to the CONTRACTOR’s records, documents, agents or employees, or premises if
reasonably required by authorized officials of the contracting agency, the Department of
Industrial Relations, or the Department of Justice to determine the contractor’s
compliance with the requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1. CONFLICT OF INTEREST: CONTRACTOR needs to be aware of the following
provisions regarding current or former state employees. If CONTRACTOR has any
questions on the status of any person rendering services or involved with this
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
a). No officer or employee shall engage in any employment, activity or
enterprise from which the officer or employee receives compensation or has a financial
interest and which is sponsored or funded by any state agency, unless the employment,
activity or enterprise is required as a condition of regular state employment.
b). No officer or employee shall contract on his or her own behalf as an
independent contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
a). For the two (2) year period from the date he or she left state employment,
no former state officer or employee may enter into a contract in which he or she
engaged in any of the negotiations, transactions, planning, arrangements or any part of
the decision-making process relevant to the contract while employed in any capacity by
any state agency.
b). For the twelve (12) month period from the date he or she left state
employment, no former state officer or employee may enter into a contract with any state
agency if he or she was employed by that state agency in a policy-making position in the
same general subject area as the proposed contract within the twelve (12) month period
prior to his or her leaving state service.
If CONTRACTOR violates any provisions of above paragraphs, such action by
CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420)
Exhibit E - Page 5 of 6
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: CONTRACTOR needs to be
aware of the provisions which require every employer to be insured against liability for
Worker's Compensation or to undertake self-insurance in accordance with the
provisions, and CONTRACTOR affirms to comply with such provisions before
commencing the performance of the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: CONTRACTOR assures the State that
it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits
discrimination on the basis of disability, as well as all applicable regulations and
guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
CONTRACTOR’s name as listed on this Agreement. Upon receipt of legal
documentation of the name change the State will process the amendment. Payment of
invoices presented with a new name cannot be paid prior to approval of said
amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the CONTRACTOR is currently qualified to do
business in California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit. Although there
are some statutory exceptions to taxation, rarely will a corporate contractor performing
within the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of
California) must be in good standing in order to be qualified to do business in California.
Agencies will determine whether a corporation is in good standing by calling the Office of
the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local governing
body, which by law has authority to enter into an agreement, authorizing execution of the
agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
CONTRACTOR shall not be: (1) in violation of any order or resolution not subject to
review promulgated by the State Air Resources Board or an air pollution control district;
(2) subject to cease and desist order not subject to review issued pursuant to Section
13301 of the Water Code for violation of waste discharge requirements or discharge
prohibitions; or (3) finally determined to be in violation of provisions of federal law
relating to air or water pollution.
Exhibit E - Page 6 of 6
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
9. INSPECTION and Audit of Records and access to Facilities.
The State, CMS, the Office of the Inspector General, the Comptroller General, and their
designees may, at any time, inspect and audit any records or documents of
CONTRACTOR or its subcontractors, and may, at any time, inspect the premises,
physical facilities, and equipment where Medicaid-related activities or work is conducted.
The right to audit under this section exists for ten (10) years from the final date of the
contract period or from the date of completion of any audit, whichever is later.
Federal database checks.
Consistent with the requirements at § 455.436 of this chapter, the State must confirm the
identity and determine the exclusion status of CONTRACTOR, any subcontractor, as
well as any person with an ownership or control interest, or who is an agent or managing
employee of CONTRACTOR through routine checks of Federal databases. This
includes the Social Security Administration's Death Master File, the National Plan and
Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE),
the System for Award Management (SAM), and any other databases as the State or
Secretary may prescribe. These databases must be consulted upon contracting and no
less frequently than monthly thereafter. If the State finds a party that is excluded, it must
promptly notify the CONTRACTOR and take action consistent with § 438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under this
part is not located outside of the United States and that no claims paid by a
CONTRACTOR to a network provider, out-of-network provider, subcontractor or financial
institution located outside of the U.S. are considered in the development of actuarially
sound capitation rates.
Exhibit F- Page 1 of 2
FRESNO COUNTY MENTAL HEALTH PLAN
INCIDENT REPORTING
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
•The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes the form, and the supervisor co-signs it.
•When more than one client is involved in an incident, a separate form must be completed for
each client.
Where the forms should be sent – within 24 hours from the time of the incident or first
knowledge of the incident:
•Incident Report should be sent to:
DBHIncidentreporting@fresnocountyca.gov and designated Contract Analyst
Fresno County Department of Behavioral Health-Incident Report
Send completed forms to dbhincidentreporting@fresnocountyca.gov 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/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 08/18
Exhibit F- Page 1 of 2
Exhibit G - Page 1 of 2
Vendor:Contract#Contact Person Contact#
Item Make/Brand Model Serial #Fixed AssetSensitive ItemDate
Requested
(If Fixed
Asset)
Date
Approved (
If Fixed
Assset)
Purchase
Date Location Condition
Fresno
County
Inventory
Number
Cost
ExampleCopier Canon 27CRT 9YHJY65R x 3/27/2008 4/1/2008 4/10/2008 Heritage New $6,500.00
ExampleDVD Player Sony DV2230 PXC4356A x n/a n/a 4/1/2008 Heritage New $450.00
Date Prepared:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Date Received:
Fixed Asset and Sensitive Item Tracking
Fi el d Number
Fi el d
Descri pt i on
I nst r uct i on or Comment s
Requi r ed or
Condi t i onal
Header Vendor I ndi cat e t he l egal name of t he agency cont r act ed t o
pr ovi de ser vi ces.
Requi r ed
Header Pr ogr am
I ndi cat e t he t i t l e of t he pr oj ect as descr i bed i n t he
cont r act wi t h t he Count y.
Requi r ed
Header Cont r act #
I ndi cat e t he assi gned Count y cont r act number . I f not
known, Count y st af f can pr ovi de.
Requi r ed
Header Cont act Per son
I ndi cat e t he f i r st and l ast name of t he pr i mar y agency
cont act f or t he cont r act .
Requi r ed
Header Cont act #
I ndi cat e t he most appr opr i at e t el ephone number of t he
pr i mar y agency cont act f or t he cont r act .
Requi r ed
Header Dat e Pr epar ed
I ndi cat e t he most cur r ent dat e t hat t he t r acki ng f or m
was compl et ed by t he vendor .
Requi r ed
a Item I dent i f y t he i t em by pr ovi di ng a commonl y r ecogni zed
descr i pt i on of t he i t em.
Requi r ed
b Make/ Br and I dent i f y t he company t hat manuf act ur ed t he i t em.Requi r ed
c Model I dent i f y t he model number f or t he i t em, i f appl i cabl e.Condi t i onal
d Ser i al #
I dent i f y t he ser i al number f or t he i t em, i f
appl i cabl e.
Condi t i onal
e Fi xed Asset
Mar k t he box wi t h an " X" i f t he cost of t he i t em i s
$5, 000 or mor e t o i ndi cat e t hat t he i t em i s a f i xed
asset .
Condi t i onal
f Sensi t i ve I t em
Mar k t he box wi t h an " X" i f t he i t em meet s t he
cr i t er i a of a sensi t i ve i t em as def i ned by t he Count y.
Condi t i onal
g Dat e Request ed
I ndi cat e t he dat e t hat t he agency submi t t ed a r equest
t o t he Count y t o pur chase t he i t em.
Requi r ed
h Dat e Appr oved
I ndi cat e t he dat e t hat t he Count y appr oved t he r equest
t o pur chase t he i t em.
Requi r ed
i Pur chase Dat e I ndi cat e t he dat e t he agency pur chased t he i t em.Requi r ed
j Locat i on I ndi cat e t he physi cal l ocat i on of t he i t em Requi r ed
k Condi t i on
I ndi cat e t he gener al condi t i on of t he i t em ( New, Good,
Wor n, Bad) .
Requi r ed
l
Fr esno Count y
I nvent or y
Number
I ndi cat e t he FR # pr ovi ded by t he Count y f or t he i t em.Condi t i onal
m Cos t
I ndi cat e t he t ot al pur chase pr i ce of t he i t em
i ncl udi ng sal es t ax and ot her cost s, such as shi ppi ng.
Requi r ed
FI XED ASSET AND SENSI TI VE I TEM TRACKI NG
Exhibit G - Page 2 of 2
EXHIBIT H - 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(S) shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, CONTRACTOR(S), CONTRACTOR(S)’ employees and
subcontractors 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.
EXHIBIT H - Page 2 of 3
7. Bill only for eligible services actually rendered and fully documented. Use billing codes
that 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(S) 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 H - 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 hereby 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 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.
Informal provider problem resolution process – the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
Exhibit I - Page 2 of 2
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 by the MHP is final.
Exhibit J
NOTICE OF CHILD ABUSE REPORTING LAW
The undersigned hereby acknowledges that Penal Code section 11166 and the
contractual obligations between County of Fresno (COUNTY) and CONTRACTOR
related to the provision of Local Outreach to Suicide Survivors Team, require that the
undersigned report all known or suspected child abuse or neglect to one or more of the
agencies set forth in Penal Code (PC) section (§) 11165.9.
For purposes of the undersigned’s child abuse reporting requirements, “child
abuse or neglect” includes physical injury inflicted by other than accidental means upon
a child by another person, sexual abuse as defined in PC §11165.1, neglect as defined
in PC §11165.2, willful cruelty or unjustifiable punishment as defined in PC §11165.3,
and unlawful corporal punishment or injury as defined in PC §11165.4.
A child abuse report shall be made whenever the undersigned, in his or her
professional capacity or within the scope of his or her employment, has knowledge of or
observes a child whom the undersigned knows or reasonably suspects has been the
victim of child abuse or neglect. (PC §11166.) The child abuse report shall be made to
any police department or sheriff’s department (not including a school district police or
security department), or to any county welfare department, including Fresno County
Department of Social Services’ 24 Hour CARELINE. (See PC §11165.9.)
For purposes of child abuse reporting, a “reasonable suspicion” means that it is
objectively reasonable for a person to entertain a suspicion, based upon facts that could
cause a reasonable person in a like position, drawing, when appropriate, on his or her
training and experience, to suspect child abuse or neglect. The pregnancy of a child
does not, in and of itself, constitute a basis for reasonable suspicion of sexual abuse.
(PC §11166(a)(1).)
Substantial penalties may be imposed for failure to comply with these child abuse
reporting requirements.
Further information and a copy of the law may be obtained from the department
head or designee.
I have read and understand the above statement and agree to comply with the
child abuse reporting requirements.
SIGNATURE _____________________________ DATE ______________________
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 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit 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.
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;
Exhibit L - Page 2 of 2
(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 TRANSAC TION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “COUNTY”),
members of a CONTRACTOR(S)’ board of directors (hereinafter referred to as “County
Contractor”), must disclose any self-dealing transactions that they are a party to while
providing goods, performing services, or both for the COUNTY. A self-dealing transaction is
defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to
the COUNTY. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the
transaction; and
b. The nature of the material financial interest in the corporation’s transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit 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: