HomeMy WebLinkAboutAgreement A-24-370 with Hinds Hospice.pdf Agreement No. 24-370
1 SERVICE AGREEMENT
2 This Service Agreement ("Agreement") is dated July 9, 2024 and is between
3 Hinds Hospice, a California non-profit corporation ("Contractor"), and the County of Fresno, a
4 political subdivision of the State of California ("County").
5 Recitals
6 A. The County, through its DBH, is a Mental Health Plan (MHP) as defined in Title 9 of the
7 California Code of Regulations, section 1810.226.
8 B. County's DBH is committed to raising awareness, providing education and training on
9 suicide prevention, and reducing stigma.
10 C. County's DBH through its Mental Health Services Act (MHSA) Prevention and Early
11 Intervention (PEI) component, and through input from the Fresno County Suicide Prevention
12 Collaborative and community stakeholder process, recognizes the need of a qualified agency to
13 operate a Local Outreach to Suicide Survivors (LOSS) Team in Fresno County to help provide
14 immediate assistance to suicide survivors to help them cope with the trauma of their loss,
15 provide follow-up contact with the survivors, and coordinate the utilization of services and
16 support groups within the community.
17 D. The Contractor is uniquely qualified, willing and able to provide services required by the
18 County, pursuant to the terms and conditions of this Agreement.
19 The parties therefore agree as follows:
20 Article 1
21 Contractor's Services
22 1.1 Scope of Services. The Contractor shall perform all of the services provided in
23 Exhibit A to this Agreement, titled "Scope of Services."
24 1.2 Representation. The Contractor represents that it is qualified, ready, willing, and
25 able to perform all of the services provided in this Agreement.
26 1.3 Compliance with Laws. The Contractor shall, at its own cost, comply with all
27 applicable federal, state, and local laws and regulations in the performance of its obligations
28 under this Agreement, including but not limited to workers compensation, labor, and
1
1 confidentiality laws and regulations.
2 Contractor shall provide services in conformance with all applicable State and Federal
3 statutes, regulations and subregulatory guidance, as from time to time amended, including but
4 not limited to:
5 (A) California Code of Regulations, Title 9;
6 (B) California Code of Regulations, Title 22;
7 (C) California Welfare and Institutions Code, Division 5;
8 (D) United States Code of Federal Regulations, Title 42, including but not limited to
9 Parts 438 and 455;
10 (E) United States Code of Federal Regulations, Title 45;
11 (F) United States Code, Title 42 (The Public Health and Welfare), as applicable;
12 (G)Balanced Budget Act of 1997;
13 (H) Health Insurance Portability and Accountability Act (HIPAA); and
14 (I) Applicable Medi-Cal laws and regulations, including applicable sub-regulatory
15 guidance, such as Behavioral Health Information Notices (BHINs), Mental Health and
16 Substance Use Disorder Services Information Notices (MHSUDS INs), and provisions of
17 County's, state or federal contracts governing services for persons served.
18 In the event any law, regulation, or guidance referred to in this section 1.3 is amended
19 during the term of this Agreement, the parties agree to comply with the amended authority as of
20 the effective date of such amendment without amending this Agreement.
21 Contractor recognizes that County operates its mental health programs under an
22 agreement with DHCS, and that under said agreement the State imposes certain requirements
23 on County and its subcontractors. Contractor shall adhere to all State requirements, including
24 those identified in Exhibit B, "Behavioral Health Requirements", attached hereto and by this
25 reference incorporated herein and made part of this Agreement.
26 1.4 Meetings. Contractor shall participate in monthly, or as needed, workgroup meetings
27 consisting of staff from County's DBH to discuss service requirements, data reporting, training,
28 policies and procedures, overall program operations and any problems or foreseeable problems
2
1 that may arise. Contractor shall also participate in other County meetings, such as but not
2 limited to quality improvement meetings, provider meetings, Behavioral Health Board meetings,
3 bi-monthly contractor meetings, etc. Schedule for these meetings may change based on the
4 needs of the County.
5 1.5 Organizational Provider. Contractor shall maintain requirements as a Mental Health
6 Plan (MHP) organizational provider throughout the term of this Agreement, as described in
7 Article 16 of this Agreement. If for any reason, this status is not maintained, County may
8 terminate this Agreement pursuant to Article 7 of this Agreement.
9 1.6 Staffing. Contractor agrees that prior to providing services under the terms and
10 conditions of this Agreement, Contractor shall have staff hired and in place for program services
11 and operations or County may, in addition to other remedies it may have, suspend referrals or
12 terminate this Agreement, in accordance with Article 7 of this Agreement.
13 1.7 Criminal Background Check. Contractor shall ensure that all providers and/or
14 subcontracted providers consent to a criminal background check, including fingerprinting to the
15 extent required under state law and 42 C.F.R. § 455.434(a). Contractor shall provide evidence
16 of completed consents when requested by the County, DHCS or the US Department of Health &
17 Human Services (US DHHS).
18 1.8 Guiding Principles. Contractor shall align programs, services, and practices with
19 the vision, mission, and guiding principles of the DBH, as further described in Exhibit C, "Fresno
20 County Department of Behavioral Health Guiding Principles of Care Delivery", attached hereto
21 and by this reference incorporated herein and made part of this Agreement.
22 1.9 Timely Access. It is the expectation of the County that Contractor provide timely
23 access to services that meet the State of California standards for care. Contractor shall track
24 timeliness of services to persons served and provide a monthly report showing the monitoring or
25 tracking tool that captures this data. County and Contractor shall meet to go over this monitoring
26 tool, as needed but at least on a monthly basis. County shall take corrective action if there is a
27 failure to comply by Contractor with timely access standards. Contractor shall also provide
28 tracking tools and measurements for effectiveness, efficiency, and persons served satisfaction
3
1 as further detailed in Exhibit A.
2 1.10 Access to Records. Contractor shall provide County with access to all
3 documentation of services provided under this Agreement for County's use in administering this
4 Agreement. Contractor shall allow County, CMS, the Office of the Inspector General, the
5 Controller General of the United States, and any other authorized Federal and State agencies to
6 evaluate performance under this Agreement, and to inspect, evaluate, and audit any and all
7 records, documents, and the premises, equipment and facilities maintained by the Contractor
8 pertaining to such services at any time and as otherwise required under this Agreement.
9 1.11 Quality Improvement Activities and Participation. Contractor shall comply with
10 the County's ongoing comprehensive Quality Assessment and Performance Improvement
11 (QAPI) Program (42 C.F.R. § 438.330(a)) and work with the County to improve established
12 outcomes by following structural and operational processes and activities that are consistent
13 with current practice standards.
14 Contractor shall participate in quality improvement (QI) activities, including clinical and
15 non-clinical performance improvement projects (PIPs), as requested by the County in relation to
16 State and Federal requirements and responsibilities, to improve health outcomes and
17 individuals' satisfaction with services over time. Other QI activities include quality assurance,
18 collection and submission of performance measures specified by the County, mechanisms to
19 detect both underutilization and overutilization of services, individual and system outcomes,
20 utilization management, utilization review, provider appeals, provider credentialing and re-
21 credentialing, and person served grievances. Contractor shall measure, monitor, and annually
22 report to the County on its performance.
23 1.12 Rights of Persons Served. Contractor shall comply with applicable laws and
24 regulations relating to patients' rights, including but not limited to Wel. & Inst. Code 5325, Cal.
25 Code Regs., tit. 9, sections 862 through 868, and 42 C. F. R. § 438.100. The Contractor shall
26 ensure that its subcontractors comply with all applicable patients' rights laws and regulations.
27
28
4
1 Article 2
2 Reporting
3 2.1 Reports. The Contractor shall submit the following reports:
4 (A) Outcome Reports
5 Contractor shall submit to County clinical program performance outcome reports,
6 as requested.
7 Outcome reports and outcome requirements are subject to change at County's
8 discretion. Contractor shall provide outcomes as stated in Exhibit A and D.
9 (B) Staffing Report
10 Contractor shall submit monthly staffing reports due by the 10th of each month
11 that identify all direct service and support staff by first and last name, applicable
12 licensure/certifications, and full-time hours worked to be used as a tracking tool to determine if
13 Contractor's program is staffed according to the requirements of this Agreement.
14 (C) Mental Health Services Act (MHSA) Reporting
15 Contractor shall adhere to MHSA reporting including but not limited to fiscal,
16 outcomes, and demographics as described in Exhibit A.
17 (D)Additional Reports
18 Contractor shall also furnish to County such statements, records, reports, data,
19 and other information as County may request pertaining to matters covered by this Agreement.
20 In the event that Contractor fails to provide such reports or other information required
21 hereunder, it shall be deemed sufficient cause for County to withhold monthly payments until
22 there is compliance. In addition, Contractor shall provide written notification and explanation to
23 County within five (5) days of any funds received from another source to conduct the same
24 services covered by this Agreement.
25 2.2 Monitoring. Contractor agrees to extend to County's staff, County's DBH and the
26 California Department of Health Care Services (DHCS), or their designees, the right to review
27 and monitor records, programs, or procedures, at any time, in regard to persons served, as well
28 as the overall operation of Contractor's programs, in order to ensure compliance with the terms
5
1 and conditions of this Agreement.
2 Article 3
3 County's Responsibilities
4 3.1 The County shall provide oversight and collaborate with Contractor, other County
5 Departments and community agencies to help achieve program goals and outcomes. In addition
6 to contractor monitoring of program, oversight includes, but not limited to, coordination with
7 Department of Health Care Services (DHCS) in regard to program administration and outcomes.
8 County shall receive and analyze statistical outcome data from Contractor throughout
9 the term of contract on a monthly basis. County shall notify the Contractor when additional
10 participation is required. The performance outcome measurement process will not be limited to
11 survey instruments but will also include, as appropriate, persons served and staff surveys, chart
12 reviews, and other methods of obtaining required information.
13 Article 4
14 Compensation, Invoices, and Payments
15 4.1 The County agrees to pay, and the Contractor agrees to receive, compensation for
16 the performance of its services under this Agreement as described in Exhibit E to this
17 Agreement, titled "Compensation."
18 4.2 MHSA Prevention and Early Intervention (PEI) Services Maximum
19 Compensation. The maximum compensation payable to the Contractor under this Agreement
20 for the period effective upon execution through June 30, 2025 for MHSA PEI Services is Two
21 Hundred Fifty-Seven Thousand, Eight Hundred Ninety-One and No/100 Dollars ($257,891).
22 The maximum compensation payable to the Contractor under this Agreement for the
23 period of July 1, 2025 through June 30, 2026 for MHSA PEI Services is Two Hundred Sixty-Six
24 Thousand, Five Hundred Twenty-Three and No/100 Dollars ($266,523).
25 The maximum compensation payable to the Contractor under this Agreement for the
26 period of July 1, 2026 through June 30, 2027 for MHSA PEI Services is Two Hundred Seventy-
27 Five Thousand, Five Hundred Seventy-Two and No/100 Dollars ($275,572).
28 The maximum compensation payable to the Contractor under this Agreement for the
6
1 period of July 1, 2027 through June 30, 2028 for MHSA PEI Services is Two Hundred Eighty-
2 Four Thousand, Nine Hundred Ninety-Three and No/100 Dollars ($284,993).
3 The maximum compensation payable to the Contractor under this Agreement for the
4 period of July 1, 2028 through June 30, 2029 for MHSA PEI Services is Two Hundred Ninety-
5 Three Thousand, Four Hundred Fourteen and No/100 Dollars ($293,414).
6 4.3 Total Maximum Compensation. In no event shall the maximum contract amount for
7 all the services provided by the Contractor to County under the terms and conditions of this
8 Agreement be in excess of One Million, Three Hundred Seventy-Eight Thousand, Three
9 Hundred Ninety-Three and No/100 Dollars ($1,378,393) during the entire term of this
10 Agreement.
11 The Contractor acknowledges that the County is a local government entity and does so
12 with notice that the County's powers are limited by the California Constitution and by State law,
13 and with notice that the Contractor may receive compensation under this Agreement only for
14 services performed according to the terms of this Agreement and while this Agreement is in
15 effect, and subject to the maximum amount payable under this section. The Contractor further
16 acknowledges that County employees have no authority to pay the Contractor except as
17 expressly provided in this Agreement.
18 The Contractor will be compensated for performance of its services under this
19 Agreement as provided in this Article. The Contractor is not entitled to any compensation except
20 as expressly provided in this Agreement.
21 4.4 Invoices. The Contractor shall submit monthly invoices, in arrears by the fifteenth
22 (151") day of each month, in the format directed by the County. The Contractor shall submit
23 invoices electronically to: 1) dbhinvoicereview@fresnocountyca.gov, and 2) dbh-
24 invoices@fresnocountyca.gov; and 3) dbhcontractedservicesdivision@fresnocountyca.gov with
25 a copy to the assigned County's DBH Staff Analyst. At the discretion of County's DBH Director
26 or designee, if an invoice is incorrect or is otherwise not in proper form or substance, County's
27 DBH Director, or designee, shall have the right to withhold payment as to only the portion of the
28 invoice that is incorrect or improper after five (5) days prior notice to Contractor. Contractor
7
1 agrees to continue to provide services for a period of ninety (90) days after notification of an
2 incorrect or improper invoice. If after the ninety (90) day period, the invoice is still not corrected
3 to County satisfaction, County's DBH Director, or designee, may elect to terminate this
4 Agreement, pursuant to the termination provisions stated in Article 7 of this Agreement.
5 Cost Reimbursement Based Invoices. Invoices for cost reimbursement services shall
6 be based on actual expenses incurred in the month of service. Contractor shall submit monthly
7 invoices and general ledgers to County that itemize the line item charges for monthly program
8 costs. The invoices and general ledgers will serve as tracking tools to determine if Contractor's
9 costs are in accordance with its budgeted cost. Failure to submit reports and other supporting
10 documentation shall be deemed sufficient cause for County to withhold payments until there is
11 compliance.
12 Contractor must report all revenue collected from a third-party, client-pay or private-pay
13 in each monthly invoice. In addition, Contractor shall submit monthly invoices for reimbursement
14 that equal the amount due less any revenue collected and/or unallowable cost such as lobbying
15 or political donations from the monthly invoice reimbursements.
16 Travel shall be reimbursed based on actual expenditures and reimbursement shall be at
17 Contractor's adopted rate, not to exceed the Federal Internal Revenue Services (IRS) published
18 rate.
19 4.5 Payment. Payments shall be made by County to Contractor in arrears, for services
20 provided during the preceding month, within forty-five (45) days after the date of receipt,
21 verification, and approval by County. All final invoices and/or any final budget modification
22 requests shall be submitted by Contractor within sixty (60) days following the final month of
23 service for which payment is claimed. No action shall be taken by County on claims submitted
24 beyond the sixty (60) day closeout period. Any compensation which is not expended by
25 Contractor pursuant to the terms and conditions of this Agreement shall automatically revert to
26 County.
27 4.6 Cost Reimbursement Payments. Payment shall be made upon certification or other
28 proof satisfactory to County that services have actually been performed by Contractor as
8
1 specified in this Agreement and/or after receipt and verification of actual expenditures incurred
2 by Contractor for monthly program costs, as identified in the budget narratives and budgets
3 identified in Exhibit E, in the performance of this Agreement. County shall not be obligated to
4 make any payments under this Agreement if the request for payment is received by County
5 more than sixty (60) days after this Agreement has terminated or expired.
6 4.7 Recoupments and Audits. County shall recapture from Contractor the value of any
7 services or other expenditures determined to be ineligible based on the County or State
8 monitoring results. The County reserves the right to enter into a repayment agreement with
9 Contractor, with total monthly payments not to exceed twelve (12) months from the date of the
10 repayment agreement, to recover the amount of funds to be recouped. The County has the
11 discretion to extend the repayment plan up to a total of twenty-four (24) months from the date of
12 the repayment agreement. The repayment agreement may be made with the signed written
13 approval of County's DBH Director, or designee, and respective Contractor through a
14 repayment agreement. The monthly repayment amounts may be netted against the Contractor's
15 monthly billing for services rendered during the month, or the County may, in its sole discretion,
16 forego a repayment agreement and recoup all funds immediately. This remedy is not exclusive,
17 and County may seek requital from any other means, including, but not limited to, a separate
18 contract or agreement with Contractor.
19 Contractor shall be held financially liable for any and all future disallowances/audit
20 exceptions due to Contractor's deficiency discovered through the State audit process and
21 County utilization review for services provided during the course of this Agreement. At County's
22 election, the disallowed amount will be remitted within forty-five (45) days to County upon
23 notification or shall be withheld from subsequent payments to Contractor. Contractor shall not
24 receive reimbursement for any units of services rendered that are disallowed or denied by the
25 Fresno County Mental Health Plan (Mental Health Plan) utilization review process or through
26 the State of California DHCS audit and review process, cost report audit settlement if applicable,
27 for Medi-Cal eligible beneficiaries.
28
9
1 4.8 Incidental Expenses. The Contractor is solely responsible for all of its costs and
2 expenses that are not specified as payable by the County under this Agreement. If Contractor
3 fails to comply with any provision of this Agreement, County shall be relieved of its obligation for
4 further compensation.
5 4.9 Restrictions and Limitations. This Agreement shall be subject to any restrictions,
6 limitations, and/or conditions imposed by County or state or federal funding sources that may in
7 any way affect the fiscal provisions of, or funding for this Agreement. This Agreement is also
8 contingent upon sufficient funds being made available by County, state, or federal funding
9 sources for the term of the Agreement. If the federal or state governments reduce financial
10 participation in the Medi-Cal program, County agrees to meet with Contractor to discuss
11 renegotiating the services required by this Agreement.
12 Funding is provided by fiscal year. Any unspent fiscal year appropriation does not roll
13 over and is not available for services provided in subsequent years.
14 In the event that funding for these services is delayed by the State Controller, County
15 may defer payments to Contractor. The amount of the deferred payment shall not exceed the
16 amount of funding delayed by the State Controller to the County. The period of time of the
17 deferral by County shall not exceed the period of time of the State Controller's delay of payment
18 to County plus forty-five (45) days.
19 4.10 Additional Financial Requirements. County has the right to monitor the
20 performance of this Agreement to ensure the accuracy of claims for reimbursement and
21 compliance with all applicable laws and regulations.
22 Contractor must comply with the False Claims Act employee training and policy
23 requirements set forth in 42 U.S.C. 1396a(a)(68) and as the Secretary of the United States
24 Department of Health and Human Services may specify.
25 Contractor agrees that no part of any federal funds provided under this Agreement shall
26 be used to pay the salary of an individual per fiscal year at a rate in excess of Level 1 of the
27 Executive Schedule at https://www.opm.gov/ (U.S. Office of Personnel Management), as from
28 time to time amended.
10
1 Federal Financial Participation is not available for any amount furnished to an Excluded
2 individual or entity, or at the direction of a physician during the period of exclusion when the
3 person providing the service knew or had reason to know of the exclusion, or to an individual or
4 entity when the County failed to suspend payments during an investigation of a credible
5 allegation of fraud [42 U.S.C. section 1396b(i)(2)].
6 Contractor must maintain financial records for a minimum period of ten (10) years or until
7 any dispute, audit or inspection is resolved, whichever is later. Contractor will be responsible for
8 any disallowances related to inadequate documentation.
9 4.11 Contractor Prohibited from Redirection of Contracted Funds. Contractor may
10 not redirect or transfer funds from one funded program to another funded program under which
11 Contractor provides services pursuant to this Agreement except through a duly executed
12 amendment to this Agreement.
13 Contractor may not charge services delivered to an eligible person served under one
14 funded program to another funded program unless the person served is also eligible for services
15 under the second funded program.
16 4.12 Financial Audit Report Requirements for Pass-Through Entities. If County
17 determines that Contractor is a "subrecipient" (also known as a "pass-through entity") as defined
18 in 2 C.F.R. § 200 et seq., Contractor represents that it will comply with the applicable cost
19 principles and administrative requirements including claims for payment or reimbursement by
20 County as set forth in 2 C.F.R. § 200 et seq., as may be amended from time to time. Contractor
21 shall observe and comply with all applicable financial audit report requirements and standards.
22 Financial audit reports must contain a separate schedule that identifies all funds included
23 in the audit that are received from or passed through the County. County programs must be
24 identified by Agreement number, Agreement amount, Agreement period, and the amount
25 expended during the fiscal year by funding source.
26 Contractor will provide a financial audit report including all attachments to the report and
27 the management letter and corresponding response within six months of the end of the audit
28 year to the County's DBH Director or designee. The County's Director or designee is
11
1 responsible for providing the audit report to the County Auditor.
2 Contractor must submit any required corrective action plan to the County simultaneously
3 with the audit report or as soon thereafter as it is available. The County shall monitor
4 implementation of the corrective action plan as it pertains to services provided pursuant to this
5 Agreement.
6 Article 5
7 Term of Agreement
8 5.1 Term. This Agreement is effective upon execution, and terminates on June 30, 2026
9 except as provided in section 5.2, "Extension," or Article 7, "Termination and Suspension,"
10 below.
11 5.2 Extension. The term of this Agreement may be extended for no more than three (3)
12 one-year period only upon written approval of both parties at least 30 days before the first day of
13 the one-year extension period. The County's DBH Director or designee is authorized to sign the
14 written approval on behalf of the County based on the Contractor's satisfactory performance.
15 The extension of this Agreement by the County is not a waiver or compromise of any default or
16 breach of this Agreement by the Contractor existing at the time of the extension whether or not
17 known to the County.
18 Article 6
19 Notices
20 6.1 Contact Information. The persons and their addresses having authority to give and
21 receive notices provided for or permitted under this Agreement include the following:
22
For the County:
23 Director
County of Fresno
24 1925 E. Dakota Avenue
Fresno, CA 93726
25
For the Contractor:
26 Chief Financial Officer
Hinds Hospice
27 2490 W. Shaw Ave
Fresno, CA 93711
28
12
1 6.2 Change of Contact Information. Either party may change the information in section
2 6.1 by giving notice as provided in section 6.3.
3 6.3 Method of Delivery. Each notice between the County and the Contractor provided
4 for or permitted under this Agreement must be in writing, state that it is a notice provided under
5 this Agreement, and be delivered either by personal service, by first-class United States mail, by
6 an overnight commercial courier service, by telephonic facsimile transmission, or by Portable
7 Document Format (PDF) document attached to an email.
8 (A) A notice delivered by personal service is effective upon service to the recipient.
9 (B) A notice delivered by first-class United States mail is effective three (3) County
10 business days after deposit in the United States mail, postage prepaid, addressed to the
11 recipient.
12 (C)A notice delivered by an overnight commercial courier service is effective one (1)
13 County business day after deposit with the overnight commercial courier service,
14 delivery fees prepaid, with delivery instructions given for next day delivery, addressed to
15 the recipient.
16 6.4 Claims Presentation. For all claims arising from or related to this Agreement,
17 nothing in this Agreement establishes, waives, or modifies any claims presentation
18 requirements or procedures provided by law, including the Government Claims Act (Division 3.6
19 of Title 1 of the Government Code, beginning with section 810).
20 6.5 Notification of Changes. Contractor shall notify County in writing of any change in
21 organizational name, Head of Service or principal business at least fifteen (15) business days in
22 advance of the change. Contractor shall notify County of a change of service location at least
23 six (6) months in advance to allow County sufficient time to comply with site certification
24 requirements. Said notice shall become part of this Agreement upon acknowledgment in writing
25 by the County, and no further amendment of the Agreement shall be necessary provided that
26 such change of address does not conflict with any other provisions of this Agreement.
27 Contractor must immediately notify County of a change in ownership, organizational
28 status, licensure, or ability of Contractor to provide the quantity or quality of the contracted
13
1 services in a and in no event more than 15 days of the change.
2 Article 7
3 Termination and Suspension
4 7.1 Termination for Non-Allocation of Funds. The terms of this Agreement are
5 contingent on the approval of funds by the appropriating government agency. If sufficient funds
6 are not allocated, then the County, upon at least thirty (30) days' advance written notice to the
7 Contractor, may:
8 (A) Modify the services provided by the Contractor under this Agreement; or
9 (B) Terminate this Agreement.
10 7.2 Termination for Breach.
11 (A) Upon determining that a breach (as defined in paragraph (C) below) has
12 occurred, the County may give written notice of the breach to the Contractor. The written
13 notice may suspend performance under this Agreement and must provide at least thirty
14 (30) days for the Contractor to cure the breach.
15 (B) If the Contractor fails to cure the breach to the County's satisfaction within the
16 time stated in the written notice, the County may terminate this Agreement immediately.
17 (C) For purposes of this section, a breach occurs when, in the determination of the
18 County, the Contractor has:
19 (1) Obtained or used funds illegally or improperly;
20 (2) Failed to comply with any part of this Agreement;
21 (3) Submitted a substantially incorrect or incomplete report to the County; or
22 (4) Improperly performed any of its obligations under this Agreement.
23 7.3 Termination without Cause. In circumstances other than those set forth above, the
24 County may terminate this Agreement by giving at least thirty (30) days advance written notice
25 to the Contractor.
26 7.4 No Penalty or Further Obligation. Any termination of this Agreement by the County
27 under this Article 7 is without penalty to or further obligation of the County.
28
14
1 7.5 County's Rights upon Termination. Upon termination for breach under this Article
2 7, the County may demand repayment by the Contractor of any monies disbursed to the
3 Contractor under this Agreement that, in the County's sole judgment, were not expended in
4 compliance with this Agreement. The Contractor shall promptly refund all such monies upon
5 demand. This section survives the termination of this Agreement.
6 In the event this Agreement is terminated, Contractor shall be entitled to compensation
7 for all Specialty Mental Health Services (SMHS) satisfactorily provided pursuant to the terms
8 and conditions of this Agreement through and including the effective date of termination. This
9 provision shall not limit or reduce any damages owed to the County due to a breach of this
10 Agreement by Contractor.
11 Article 8
12 Independent Contractor
13 8.1 Status. In performing under this Agreement, the Contractor, including its officers,
14 agents, employees, and volunteers, is at all times acting and performing as an independent
15 contractor, in an independent capacity, and not as an officer, agent, servant, employee,joint
16 venturer, partner, or associate of the County.
17 8.2 Verifying Performance. The County has no right to control, supervise, or direct the
18 manner or method of the Contractor's performance under this Agreement, but the County may
19 verify that the Contractor is performing according to the terms of this Agreement.
20 8.3 Benefits. Because of its status as an independent contractor, the Contractor has no
21 right to employment rights or benefits available to County employees. The Contractor is solely
22 responsible for providing to its own employees all employee benefits required by law. The
23 Contractor shall save the County harmless from all matters relating to the payment of
24 Contractor's employees, including compliance with Social Security withholding and all related
25 regulations.
26 8.4 Services to Others. The parties acknowledge that, during the term of this
27 Agreement, the Contractor may provide services to others unrelated to the County.
28
15
1 8.5 Operating Costs. Contractor shall provide all personnel, supplies, and operating
2 expenses of any kind required for the performance of this Agreement.
3 8.6 Additional Responsibilities. The parties acknowledge that, during the term of this
4 Agreement, the Contractor will be performing hiring, training, and credentialing of staff, and
5 County will be performing additional staff credentialing to ensure compliance with State and
6 Federal regulations.
7 8.7 Subcontracts. Contractor shall obtain written approval from County's Department of
8 Behavioral Health Director, or designee before subcontracting any of the services delivered
9 under this Agreement. County's Department of Behavioral Health Director, or designee retains
10 the right to approve or reject any request for subcontracting services. Any transferee, assignee,
11 or subcontractor will be subject to all applicable provisions of this Agreement, and all applicable
12 State and Federal regulations. Contractor shall be held primarily responsible by County for the
13 performance of any transferee, assignee, or subcontractor unless otherwise expressly agreed to
14 in writing by County's Department of Behavioral Health Director, or designee. The use of
15 subcontractors by Contractor shall not entitle Contractor to any additional compensation that is
16 provided for under this Agreement.
17 Contractor shall remain legally responsible for the performance of all terms and
18 conditions of this Agreement, including, without limitation, all services provided by third parties
19 under subcontracts, whether approved by the County or not.
20 Article 9
21 Indemnity and Defense
22 9.1 Indemnity. The Contractor shall indemnify and hold harmless and defend the
23 County (including its officers, agents, employees, and volunteers) against all claims, demands,
24 injuries, damages, costs, expenses (including attorney fees and costs), fines, penalties, and
25 liabilities of any kind to the County, the Contractor, or any third party that arise from or relate to
26 the performance or failure to perform by the Contractor (or any of its officers, agents,
27 subcontractors, or employees) under this Agreement. The County may conduct or participate in
28 its own defense without affecting the Contractor's obligation to indemnify and hold harmless or
16
1 defend the County.
2 9.2 Survival. This Article 10 survives the termination of this Agreement.
3 Article 10
4 Insurance
5 10.1 The Contractor shall comply with all the insurance requirements in Exhibit F to this
6 Agreement.
7 Article 11
8 Assurances
9 11.1 Certification of Non-exclusion or Suspension from Participation in a Federal
10 Health Care Program.
11 (A) In entering into this Agreement, Contractor certifies that it is not excluded from
12 participation in Federal Health Care Programs under either Section 1128 or 1128A of the
13 Social Security Act. Failure to so certify will render all provisions of this Agreement null
14 and void and may result in the immediate termination of this Agreement.
15 (B) In entering into this Agreement, Contractor certifies, that the Contractor does not
16 employ or subcontract with providers or have other relationships with providers excluded
17 from participation in Federal Health Care Programs, including Medi-Cal/Medicaid or
18 procurement activities, as set forth in 42 C.F.R. §438.610. Contractor shall conduct initial
19 and monthly exclusion and suspension searches of the following databases and provide
20 evidence of these completed searches when requested by County, DHCS or the US
21 Department of Health and Human Services (DHHS):
22 (1) www.oig.hhs.gov/exclusions - Office of Inspector General's List of Excluded
23 Individuals/Entities (LEIE) Federal Exclusions
24 (2) www.sam.gov/content/exclusions - General Service Administration (GSA)
25 Exclusions Extractwww.Medi-Cal.ca.gov- Suspended & Ineligible Provider List
26 (3) https://nppes.cros.hhs.gov/#/- National Plan and Provider Enumeration
27 System (NPPES)
28 (4) any other database required by DHCS or US DHHS.
17
1 (C) In entering into this Agreement, Contractor certifies, that Contractor does not
2 employ staff or individual contractors/vendors that are on the Social Security
3 Administration's Death Master File. Contractor shall check the database prior to
4 employing staff or individual contractors/vendors and provide evidence of these
5 completed searches when requested by the County, DHCS or the US DHHS.
6 (D) Contractor is required to notify County immediately if Contractor becomes aware
7 of any information that may indicate their (including employees/staff and individual
8 contractors/vendors) potential placement on an exclusions list.
9 (E) Contractor shall screen and periodically revalidate all network providers in
10 accordance with the requirements of 42 C.F.R., Part 455, Subparts B and E.
11 (F) Contractor must confirm the identity and determine the exclusion status of all its
12 providers, as well as any person with an ownership or control interest, or who is an
13 agent or managing employee of the contracted agency through routine checks of federal
14 and state databases. This includes the Social Security Administration's Death Master
15 File, NPPES, the Office of Inspector General's LEIE, the Medi-Cal Suspended and
16 Ineligible Provider List (S&I List) as consistent with the requirements of 42 C.F.R. §
17 455.436.
18 (G) If Contractor finds a provider that is excluded, it must promptly notify the County
19 as per 42 C.F.R. § 438.608(a)(2), (4). The Contractor shall not certify or pay any
20 Excluded provider with Medi-Cal funds, must treat any payments made to an excluded
21 provider as an overpayment, and any such inappropriate payments may be subject to
22 recovery.
23 Article 12
24 Inspections, Audits, and Public Records
25 12.1 Inspection of Documents. The Contractor shall make available to the County, and
26 the County may examine at any time during business hours and as often as the County deems
27 necessary, all of the Contractor's records and data with respect to the matters covered by this
28 Agreement, excluding attorney-client privileged communications. The Contractor shall, upon
18
1 request by the County, permit the County to audit and inspect all of such records and data to
2 ensure the Contractor's compliance with the terms of this Agreement.
3 12.2 State Audit Requirements. If the compensation to be paid by the County under this
4 Agreement exceeds $10,000, the Contractor is subject to the examination and audit of the
5 California State Auditor, as provided in Government Code section 8546.7, for a period of three
6 years after final payment under this Agreement. This section survives the termination of this
7 Agreement.
8 12.3 Confidentiality in Audit Process. Contractor and County mutually agree to
9 maintain the confidentiality of Contractor's records and information of persons served, in
10 compliance with all applicable State and Federal statutes and regulations, including but not
11 limited to HIPAA and California Welfare and Institutions Code, Section 5328. Contractor shall
12 inform all of its officers, employees, and agents of the confidentiality provisions of all applicable
13 statutes.
14 Contractor's fiscal records shall contain sufficient data to enable auditors to perform a
15 complete audit and shall be maintained in conformance with standard procedures and
16 accounting principles.
17 Contractor's records shall be maintained as required by DBH and DHCS on forms
18 furnished by DHCS or the County. All statistical data or information requested by the County's
19 DBH Director or designee shall be provided by the Contractor in a complete and timely manner.
20 12.4 Reasons for Recoupment. County will conduct periodic audits of Contractor files to
21 ensure appropriate clinical documentation, high quality service provision and compliance with
22 applicable federal, state and county regulations.
23 Such audits may result in requirements for Contractor to reimburse County for services
24 previously paid in the following circumstances:
25 (A) Identification of Fraud, Waste or Abuse as defined in federal regulation
26 (1) Fraud and abuse are defined in C.F.R. Title 42, § 455.2 and W&I Code,
27 section 14107.11, subdivision (d).
28 (2) Definitions for "fraud," "waste," and "abuse" can also be found in the Medicare
19
1 Managed Care Manual available at https://www.cros.gov/Regulations-and-
2 Guidance/Guidance/Manuals
3 (B) Overpayment of Contractor by County due to errors in claiming or
4 documentation.
5 (C) Other reasons specified in the SMHS Reasons for Recoupment document
6 released annually by DHCS and posted on the DHCS BHIN website.
7 Contractor shall reimburse County for all overpayments identified by Contractor, County,
8 and/or state or federal oversight agencies as an audit exception within the timeframes required
9 by law or Country or state or federal agency. Funds owed to County will be due within forty-five
10 (45) days of notification by County, or County shall withhold future payments until all excess
11 funds have been recouped by means of an offset against any payments then or thereafter owing
12 to County under this or any other Agreement between the County and Contractor.
13 12.5 Cooperation with Audits. Contractor shall cooperate with County in any review
14 and/or audit initiated by County, DHCS, or any other applicable regulatory body. This
15 cooperation may include such activities as onsite program, fiscal, or chart reviews and/or audits.
16 In addition, Contractor shall comply with all requests for any documentation or files
17 including, but not limited to, files for persons served.
18 Contractor shall notify the County of any scheduled or unscheduled external evaluation
19 or site visits when it becomes aware of such visit. County shall reserve the right to attend any or
20 all parts of external review processes.
21 Contractor shall allow inspection, evaluation and audit of its records, documents and
22 facilities for ten (10) years from the term end date of this Agreement or in the event Contractor
23 has been notified that an audit or investigation of this Agreement has been commenced, until
24 such time as the matter under audit or investigation has been resolved, including the exhaustion
25 of all legal remedies, whichever is later pursuant to 42 C.F.R.§§ 438.3(h) and 438.2301(3)(i-iii).
26 12.6 Single Audit Clause. If Contractor expends Seven Hundred Fifty Thousand and
27 No/100 Dollars ($750,000.00) or more in Federal and Federal flow-through monies, Contractor
28 agrees to conduct an annual audit in accordance with the requirements of the Single Audit
20
1 Standards as set forth in Office of Management and Budget (OMB) 2 CFR 200. Contractor shall
2 submit said audit and management letter to County. The audit must include a statement of
3 findings or a statement that there were no findings. If there were negative findings, Contractor
4 must include a corrective action plan signed by an authorized individual. Contractor agrees to
5 take action to correct any material non-compliance or weakness found as a result of such audit.
6 Such audit shall be delivered to County's DBH Finance Division for review within nine (9)
7 months of the end of any fiscal year in which funds were expended and/or received for the
8 program. Failure to perform the requisite audit functions as required by this Agreement may
9 result in County performing the necessary audit tasks, or at County's option, contracting with a
10 public accountant to perform said audit, or may result in the inability of County to enter into
11 future agreements with Contractor. All audit costs related to this Agreement are the sole
12 responsibility of Contractor.
13 A single audit report is not applicable if Contractor's Federal contracts do not exceed the
14 Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or Contractor's
15 only funding is through Drug-related Medi-Cal. If a single audit is not applicable, a program audit
16 must be performed and a program audit report with management letter shall be submitted by
17 Contractor to County as a minimum requirement to attest to Contractor solvency. Said audit
18 report shall be delivered to County's DBH Finance Division for review no later than nine (9)
19 months after the close of the fiscal year in which the funds supplied through this Agreement are
20 expended. Failure to comply with this Act may result in County performing the necessary audit
21 tasks or contracting with a qualified accountant to perform said audit. All audit costs related to
22 this Agreement are the sole responsibility of Contractor who agrees to take corrective action to
23 eliminate any material noncompliance or weakness found as a result of such audit. Audit work
24 performed by County under this paragraph shall be billed to Contractor at County cost, as
25 determined by County's Auditor-Controller/Treasurer-Tax Collector.
26 Contractor shall make available all records and accounts for inspection by County, the
27 State of California, if applicable, the Controller General of the United States, the Federal Grantor
28 Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
21
1 least three (3) years following final payment under this Agreement or the closure of all other
2 pending matters, whichever is later.
3 12.7 Public Records. The County is not limited in any manner with respect to its public
4 disclosure of this Agreement or any record or data that the Contractor may provide to the
5 County. The County's public disclosure of this Agreement or any record or data that the
6 Contractor may provide to the County may include but is not limited to the following:
7 (A) The County may voluntarily, or upon request by any member of the public or
8 governmental agency, disclose this Agreement to the public or such governmental
9 agency.
10 (B) The County may voluntarily, or upon request by any member of the public or
11 governmental agency, disclose to the public or such governmental agency any record or
12 data that the Contractor may provide to the County, unless such disclosure is prohibited
13 by court order.
14 (C)This Agreement, and any record or data that the Contractor may provide to the
15 County, is subject to public disclosure under the Ralph M. Brown Act (California
16 Government Code, Title 5, Division 2, Part 1, Chapter 9, beginning with section 54950).
17 (D)This Agreement, and any record or data that the Contractor may provide to the
18 County, is subject to public disclosure as a public record under the California Public
19 Records Act (California Government Code, Title 1, Division 7, Chapter 3.5, beginning
20 with section 6250) ("CPRA").
21 (E) This Agreement, and any record or data that the Contractor may provide to the
22 County, is subject to public disclosure as information concerning the conduct of the
23 people's business of the State of California under California Constitution, Article 1,
24 section 3, subdivision (b).
25 (F) Any marking of confidentiality or restricted access upon or otherwise made with
26 respect to any record or data that the Contractor may provide to the County shall be
27 disregarded and have no effect on the County's right or duty to disclose to the public or
28 governmental agency any such record or data.
22
1 12.8 Public Records Act Requests. If the County receives a written or oral request
2 under the CPRA to publicly disclose any record that is in the Contractor's possession or control,
3 and which the County has a right, under any provision of this Agreement or applicable law, to
4 possess or control, then the County may demand, in writing, that the Contractor deliver to the
5 County, for purposes of public disclosure, the requested records that may be in the possession
6 or control of the Contractor. Within five business days after the County's demand, the
7 Contractor shall (a) deliver to the County all of the requested records that are in the Contractor's
8 possession or control, together with a written statement that the Contractor, after conducting a
9 diligent search, has produced all requested records that are in the Contractor's possession or
10 control, or (b) provide to the County a written statement that the Contractor, after conducting a
11 diligent search, does not possess or control any of the requested records. The Contractor shall
12 cooperate with the County with respect to any County demand for such records. If the
13 Contractor wishes to assert that any specific record or data is exempt from disclosure under the
14 CPRA or other applicable law, it must deliver the record or data to the County and assert the
15 exemption by citation to specific legal authority within the written statement that it provides to
16 the County under this section. The Contractor's assertion of any exemption from disclosure is
17 not binding on the County, but the County will give at least 10 days' advance written notice to
18 the Contractor before disclosing any record subject to the Contractor's assertion of exemption
19 from disclosure. The Contractor shall indemnify the County for any court-ordered award of costs
20 or attorney's fees under the CPRA that results from the Contractor's delay, claim of exemption,
21 failure to produce any such records, or failure to cooperate with the County with respect to any
22 County demand for any such records.
23 Article 13
24 Right to Monitor
25 13.1 Right to Monitor. County or any subdivision or appointee thereof, and the State of
26 California or any subdivision or appointee thereof, including the Auditor General, shall have
27 absolute right to review and audit all records, books, papers, documents, corporate minutes,
28 financial records, staff information, records of persons served, other pertinent items as
23
1 requested, and shall have absolute right to monitor the performance of Contractor in the delivery
2 of services provided under this Agreement. Full cooperation shall be given by the Contractor in
3 any auditing or monitoring conducted, according to this agreement.
4 13.2 Accessibility. Contractor shall make all of its premises, physical facilities,
5 equipment, books, records, documents, agreements, computers, or other electronic systems
6 pertaining to Medi-Cal enrollees, Medi-Cal-related activities, services, and activities furnished
7 under the terms of this Agreement, or determinations of amounts payable available at any time
8 for inspection, examination, or copying by County, the State of California or any subdivision or
9 appointee thereof, CMS, U.S. Department of Health and Human Services (HHS) Office of
10 Inspector General, the United States Controller General or their designees, and other
11 authorized federal and state agencies. This audit right will exist for at least ten years from the
12 final date of the Agreement period or in the event the Contractor has been notified that an audit
13 or investigation of this Agreement has commenced, until such time as the matter under audit or
14 investigation has been resolved, including the exhaustion of all legal remedies, whichever is
15 later (42 CFR §438.230(c)(3)(I)-(ii)).
16 The County, DHCS, CMS, or the HHS Office of Inspector General may inspect,
17 evaluate, and audit the Contractor at any time if there is a reasonable possibility of fraud or
18 similar risk. The Department's inspection shall occur at the Contractor's place of business,
19 premises, or physical facilities (42 CFR §438.230(c)(3)(iv)).
20 13.3 Cooperation. Contractor shall cooperate with County in the implementation,
21 monitoring and evaluation of this Agreement and comply with any and all reporting requirements
22 established by County. Should County identify an issue or receive notification of a complaint or
23 potential/actual/suspected violation of requirements, County may audit, monitor, and/or request
24 information from Contractor to ensure compliance with laws, regulations, and requirements, as
25 applicable.
26 13.4 Probationary Status. County reserves the right to place Contractor on probationary
27 status, as referenced in the Probationary Status Article, should Contractor fail to meet
28 performance requirements; including, but not limited to violations such as high disallowance
24
1 rates, failure to report incidents and changes as contractually required, failure to correct issues,
2 inappropriate invoicing, untimely and inaccurate data entry, not meeting performance outcomes
3 expectations, and violations issued directly from the State. Additionally, Contractor may be
4 subject to Probationary Status or termination if agreement monitoring and auditing corrective
5 actions are not resolved within specified timeframes.
6 13.5 Record Retention. Contractor shall retain all records and documents originated or
7 prepared pursuant to Contractor's performance under this Agreement, including grievance and
8 appeal records, and the data, information and documentation specified in 42 C.F.R. parts
9 438.604, 438.606, 438.608, and 438.610 for a period of no less than ten years from the term
10 end date of this Agreement or until such time as the matter under audit or investigation has
11 been resolved. Records and documents include but are not limited to all physical and electronic
12 records and documents originated or prepared pursuant to Contractor's or subcontractor's
13 performance under this Agreement including working papers, reports, financial records and
14 documents of account, records of persons served, prescription files, subcontracts, and any
15 other documentation pertaining to covered services and other related services for persons
16 served.
17 13.6 Record Maintenance. Contractor shall maintain all records and management books
18 pertaining to service delivery and demonstrate accountability for agreement performance and
19 maintain all fiscal, statistical, and management books and records pertaining to the program.
20 Records should include, but not be limited to, monthly summary sheets, sign-in sheets, and
21 other primary source documents. Fiscal records shall be kept in accordance with Generally
22 Accepted Accounting Principles and must account for all funds, tangible assets, revenue and
23 expenditures. Fiscal records must also comply with the Code of Federal Regulations (CFR),
24 Title II, Subtitle A, Chapter 11, Part 200, Uniform Administrative Requirements, Cost Principles,
25 and Audit Requirements for Federal Awards.
26 All records shall be complete and current and comply with all Agreement requirements.
27 Failure to maintain acceptable records per the preceding requirements shall be considered
28 grounds for withholding of payments for billings submitted and for termination of Agreement.
25
1 Contractor shall maintain records of persons served and community service in
2 compliance with all regulations set forth by local, state, and federal requirements, laws, and
3 regulations, and provide access to clinical records by County staff.
4 Contractor shall comply with the Article 18 and Article 1 regarding relinquishing or
5 maintaining medical records.
6 Contractor shall agree to maintain and retain all appropriate service and financial
7 records for a period of at least ten (10) years from the date of final payment, the final date of the
8 contract period, final settlement, or until audit findings are resolved, whichever is later.
9 13.7 Financial Reports. Contractor shall submit audited financial reports on an annual
10 basis to the County. The audit shall be conducted in accordance with Generally Accepted
11 Accounting Principles and generally accepted auditing standards.
12 13.8 Agreement Termination. In the event the Agreement is terminated, ends its
13 designated term or Contractor ceases operation of its business, Contractor shall deliver or make
14 available to County all financial records that may have been accumulated by Contractor or
15 subcontractor under this Agreement, whether completed, partially completed or in progress
16 within seven (7) calendar days of said termination/end date.
17 13.9 Facilities and Assistance. Contractor shall provide all reasonable facilities and
18 assistance for the safety and convenience of the County's representatives in the performance of
19 their duties. All inspections and evaluations shall be performed in such a manner that will not
20 unduly delay the work of Contractor.
21 13.10 County Discretion to Revoke. County has the discretion to revoke full or partial
22 provisions of the Agreement, delegated activities or obligations, or application of other remedies
23 permitted by state or federal law when the County or DHCS determines Contractor has not
24 performed satisfactorily.
25 13.11 Site Inspection. Without limiting any other provision related to inspections or audits
26 otherwise set forth in this Agreement, Contractor shall permit authorized County, state, and/or
27 federal agency(ies), through any authorized representative, the right to inspect or otherwise
28 evaluate the work performed or being performed hereunder including subcontract support
26
1 activities and the premises which it is being performed. Contractor shall provide all reasonable
2 assistance for the safety and convenience of the authorized representative in the performance
3 of their duties. All inspections and evaluations shall be made in a manner that will not unduly
4 delay the work of the Contractor.
5 Article 14
6 Complaints Logs and Grievances
7 14.1 Documentation. Contractor shall log complaints and the disposition of all complaints
8 from a person served or their family. Contractor shall provide a copy of the detailed complaint
9 log entries concerning County-sponsored persons served to County at monthly intervals by the
10 tenth (10th) day of the following month, in a format that is mutually agreed upon. Contractor
11 shall allow beneficiaries or their representative to file a grievance either orally, or in writing at
12 any time with the Mental health Plan. In the event Contractor is notified by a beneficiary or their
13 representative of a discrimination grievance, subcontractor shall report discrimination
14 grievances to the Mental Health Plan within 24 hours. The Contractor shall not require a
15 beneficiary or their representative to file a Discrimination Grievance with the Mental Health Plan
16 before filing the complaint directly with the DHCS Office of Civil Rights and the U.S. Health and
17 Human Services Office for Civil Rights.
18 14.2 Rights of Persons Served. Contractor shall post signs informing persons served of
19 their right to file a complaint or grievance, appeals, and expedited appeals. In addition,
20 Contractor shall inform every person served of their rights as set forth in Exhibit G.
21 14.3 Incident Reporting. Contractor shall file an incident report for all incidents involving
22 persons served, following the protocol identified in Exhibit H.
23 Article 15
24 Property of County
25 15.1 Applicability. Article 15 shall only apply to the program components and services
26 provided under operational costs.
27 15.2 Fixed Assets. County and Contractor recognize that fixed assets are tangible and
28 intangible property obtained or controlled under County for use in operational capacity and will
27
1 benefit County for a period more than one (1) year.
2 15.3 Agreement Assets. Assets shall be tracked on an agreement by agreement basis.
3 All of these assets shall fall into the "Equipment" category unless funding source allows for
4 additional types of assets. At a minimum, the following types of items are considered to be
5 assets:
6 (A) Computers (desktops and laptops)*
7 (B) Copiers, cell phones, tablets, and other devices with any HIPAA data
8 (C) Modular furniture
9 (D)Any items over $500 or more with a lifespan of at least two (2) years:
10 (1) Televisions
11 (2) Washers/Dryers
12 (3) Printers
13 (4) Digital Cameras
14 (5) Other equipment/furniture
15 (6) Items in total when purchased or used as a group fall into one or more of the
16 above categories
17 (E) Items of sensitive nature shall be purchased and allocated to a single agreement.
18 All items containing HIPAA data are considered sensitive.
19 Contractor shall ensure proper tracking for contact assets that include the following
20 asset attributes at a minimum:
21 (A) Description of the asset;
22 (B) The unique identifier of the asset if applicable, i.e., serial number;
23 (C)The acquisition date;
24 (D)The quantity of the asset;
25 (E) The location of the asset or to whom the asset is assigned;
26 (F) The cost of the asset at the time of acquisition;
27 (G)The source of grant funding if applicable;
28 (H)The disposition date, and
28
1 (1) The method of disposition (surplus, transferred, destroyed, lost)
2 All Contract assets shall be returned to the Department at the end of the agreement
3 period.
4 15.4 Retention and Maintenance. Assets shall be retained by County, as County
5 property, in the event this Agreement is terminated or upon expiration of this Agreement.
6 Contractor agrees to participate in an annual inventory of all County fixed and inventoried
7 assets. Upon termination or expiration of this Agreement, Contractor shall be physically present
8 when fixed and inventoried assets are returned to County possession. Contractor is responsible
9 for returning to County all County owned undepreciated fixed and inventoried assets, or the
10 monetary value of said assets if unable to produce the assets at the expiration or termination of
11 this Agreement. Contractor further agrees to the following:
12 Maintain all items of equipment in good working order and condition, normal wear and
13 tear excepted;
14 Label all items of equipment with County assigned program number, to perform periodic
15 inventories as required by County and to maintain an inventory list showing where and how the
16 equipment is being used in accordance with procedures developed by County. All such lists
17 shall be submitted to County within ten (10) days of any request therefore; and
18 Report in writing to County immediately after discovery, the loss or theft of any items of
19 equipment. For stolen items, the local law enforcement agency must be contacted, and a copy
20 of the police report submitted to County.
21 15.5 Equipment Purchase. The purchase of any equipment by Contractor with funds
22 provided hereunder shall require the prior written approval of County's DBH Director or
23 designee, shall fulfill the provisions of this Agreement as appropriate, and must be directly
24 related to Contractor's services or activity under the terms of this Agreement. County may
25 refuse reimbursement for any costs resulting from equipment purchased, which are incurred by
26 Contractor, if prior written approval has not been obtained from County.
27 15.6 Modification. Contractor must obtain prior written approval from County's DBH
28 whenever there is any modification or change in the use of any property acquired or improved,
29
1 in whole or in part, using funds under this Agreement. If any real or personal property acquired
2 or improved with said funds identified herein is sold and/or is utilized by Contractor for a use
3 which does not qualify under this Agreement, Contractor shall reimburse County in an amount
4 equal to the current fair market value of the property, less any portion thereof attributable to
5 expenditures of funds not provided under this Agreement. These requirements shall continue in
6 effect for the life of the property. In the event this Agreement expires, the requirements for this
7 Article shall remain in effect for activities or property funded with said funds, unless action is
8 taken by the State government to relieve County of these obligations.
9 Article 16
10 Compliance
11 16.1 Compliance. Contractor agrees to comply with County's Contractor Code of
12 Conduct and Ethics and the County's Compliance Program in accordance with Exhibit I. Within
13 thirty (30) days of entering into this Agreement with County, Contractor shall ensure all of
14 Contractor's employees, agents, and subcontractors providing services under this Agreement
15 certify in writing, that he or she has received, read, understood, and shall abide by the
16 Contractor Code of Conduct and Ethics. Contractor shall ensure that within thirty (30) days of
17 hire, all new employees, agents, and subcontractors providing services under this Agreement
18 shall certify in writing that he or she has received, read, understood, and shall abide by the
19 Contractor Code of Conduct and Ethics. Contractor understands that the promotion of and
20 adherence to the Contractor Code of Conduct is an element in evaluating the performance of
21 Contractor and its employees, agents, and subcontractors.
22 Within thirty (30) days of entering into this Agreement, and annually thereafter, all
23 employees, agents, and subcontractors providing services under this Agreement shall complete
24 general compliance training, and appropriate employees, agents, and subcontractors shall
25 complete documentation and billing or billing/reimbursement training. All new employees,
26 agents, and subcontractors shall attend the appropriate training within thirty (30) days of hire.
27 Each individual who is required to attend training shall certify in writing that he or she has
28 received the required training. The certification shall specify the type of training received and
30
1 the date received. The certification shall be provided to County's DBH Compliance Officer at
2 1925 E. Dakota Ave, Fresno, California 93726. Contractor agrees to reimburse County for the
3 entire cost of any penalty imposed upon County by the Federal Government as a result of
4 Contractor's violation of the terms of this Agreement.
5 16.2 Compliance Program, Including Fraud Prevention and Overpayments.
6 Contractor shall have in place a compliance program designed to detect and prevent fraud,
7 waste and abuse, as per 42 C.F.R. § 438.608(a)(1), that must include:
8 (A) Written policies, procedures, and standards of conduct that articulate the
9 organization's commitment to comply with all applicable requirements and standards
10 under the Agreement, and all applicable federal and state requirements.
11 (B) A Compliance Office (CO) who is responsible for developing and implementing
12 policies, procedures, and practices designed to ensure compliance with the
13 requirements of this Agreement and who reports directly to the CEO and the Board of
14 Directors.
15 (C)A Regulatory Compliance Committee on the Board of Directors and at the senior
16 management level charged with overseeing the organization's compliance program and
17 its compliance with the requirements under the Agreement.
18 (D)A system for training and education for the Compliance Officer, the organization's
19 senior management, and the organization's employees for the federal and state
20 standards and requirements under the Agreement.
21 (E) Effective lines of communication between the Compliance Officer and the
22 organization's employees.
23 (F) Enforcement of standards through well-publicized disciplinary guidelines.
24 (G)The establishment and implementation of procedures and a system with
25 dedicated staff for routine internal monitoring and auditing of compliance risks, prompt
26 response to compliance issues as they are raised, investigation of potential compliance
27 problems as identified in the course of self-evaluation and audits, corrections of such
28 problems promptly and thoroughly to reduce the potential for recurrence and ongoing
31
1 compliance with the requirements under the Agreement.
2 (H)The requirement for prompt reporting and repayment of any overpayments
3 identified.
4 16.3 Reporting. Contractor must have administrative and management arrangements or
5 procedures designed to detect and prevent fraud, waste and abuse of federal or state health
6 care funding. Contractor must report fraud and abuse information to the County including but
7 not limited to:
8 (A) Any potential fraud, waste, or abuse as per 42 C.F.R. § 438.608(a), (a)(7),
9 (B) All overpayments identified or recovered, specifying the overpayment due to
10 potential fraud as per 42 C.F.R. § 438.608(a), (a)(2),
11 (C) Information about changes in a persons served's circumstances that may affect
12 the person served's eligibility including changes in their residence or the death of the
13 person served as per 42 C.F.R. § 438.608(a)(3).
14 (D) Information about a change in the Contractor's circumstances that may affect the
15 network provider's eligibility to participate in the managed care program, including the
16 termination of this Agreement with the Contractor as per 42 C.F.R. § 438.608(a)(6).
17 Contractor shall implement written policies that provide detailed information about the
18 False Claims Act ("Act") and other federal and state laws described in section 1902(a)(68) of the
19 Act, including information about rights of employees to be protected as whistleblowers.
20 Contractor shall make prompt referral of any potential fraud, waste or abuse to County or
21 potential fraud directly to the State Medicaid Fraud Control Unit.
22 16.4 Overpayments. County may suspend payments to Contractor if DHCS or County
23 determine that there is a credible allegation of fraud in accordance with 42 C.F.R. §455.23. (42
24 C.F.R. §438.608 (a)(8)).
25 Contractor shall report to County all identified overpayments and reason for the
26 overpayment, including overpayments due to potential fraud. Contractor shall return any
27 overpayments to the County within 60 calendar days after the date on which the overpayment
28 was identified. (42 C.F.R. § 438.608 (a)(2), (c)(3)).
32
1 Article 17
2 Federal and State Laws
3 17.1 Health Insurance Portability and Accountability Act. County and Contractor each
4 consider and represent themselves as covered entities as defined by the U.S. Health Insurance
5 Portability and Accountability Act of 1996, Public Law 104-191(HIPAA) and agree to use and
6 disclose Protected Health Information (PHI) as required by law.
7 County and Contractor acknowledge that the exchange of PHI between them is only for
8 treatment, payment, and health care operations.
9 County and Contractor intend to protect the privacy and provide for the security of PHI
10 pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
11 Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated
12 thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations) and
13 other applicable laws.
14 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
15 Contractor to enter into an agreement containing specific requirements prior to the disclosure of
16 PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e)
17 of the Code of Federal Regulations. The parties agree to the terms of the Business Associate
18 Agreement attached as Exhibit O.
19 17.2 Physical Accessibility. In accordance with the accessibility requirements of section
20 508 of the Rehabilitation Act and the Americans with Disabilities Act of 1973, Contractor must
21 provide physical access, reasonable accommodations, and accessible equipment for Medi-Cal
22 beneficiaries with physical or mental disabilities.
23 Article 18
24 Data Security
25 18.1 Data Security Requirements. Contractor shall comply with data security
26 requirements in Exhibit J to this Agreement.
27
28
33
1 Article 19
2 Publicity Prohibition
3 19.1 Self-Promotion. None of the funds, materials, property, or services provided directly
4 or indirectly under this Agreement shall be used for Contractor's advertising, fundraising, or
5 publicity (i.e., purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-
6 promotion.
7 19.2 Public Awareness. Notwithstanding the above, publicity of the services described in
8 Article 1 of this Agreement shall be allowed as necessary to raise public awareness about the
9 availability of such specific services when approved in advance by County's DBH Director or
10 designee and at a cost to be provided in Exhibit E for such items as written/printed materials,
11 the use of media (i.e., radio, television, newspapers), and any other related expense(s).
12 Communication products must follow DBH graphic standards, including typefaces and colors, to
13 communicate our authority and project a unified brand. This includes all media types and
14 channels and all materials on and offline that are created as part of DBH's efforts to provide
15 information to the public.
16 Article 20
17 Disclosure of Self-Dealing Transactions
18 20.1 Applicability. This Article 20 applies if the Contractor is operating as a corporation,
19 or changes its status to operate as a corporation.
20 20.2 Duty to Disclose. If any member of the Contractor's board of directors is party to a
21 self-dealing transaction, he or she shall disclose the transaction by completing and signing a
22 "Self-Dealing Transaction Disclosure Form" (Exhibit K to this Agreement) and submitting it to the
23 County before commencing the transaction or immediately after.
24 20.3 Definition. "Self-dealing transaction" means a transaction to which the Contractor is
25 a party and in which one or more of its directors, as an individual, has a material financial
26 interest.
27 1H
28 1H
34
1 Article 21
2 Disclosure of Ownership and/or Control Interest Information
3 21.1 Applicability. This provision is only applicable if Contractor is disclosing entities,
4 fiscal agents, or managed care entities, as defined in Code of Federal Regulations (C.F.R.),
5 Title 42 §§ 455.101, 455.104 and 455.106(a)(1),(2).
6 21.2 Duty to Disclose. Contractor must disclose the following information as requested in
7 the Provider Disclosure Statement, Disclosure of Ownership and Control Interest Statement,
8 Exhibit L:
9 (A) Disclosure of 5% or More Ownership Interest:
10 (1) In the case of corporate entities with an ownership or control interest in the
11 disclosing entity, the primary business address as well as every business location
and P.O. Box address must be disclosed. In the case of an individual, the date of
12
birth and Social Security number must be disclosed.
13 (2) In the case of a corporation with ownership or control interest in the
14 disclosing entity or in any subcontractor in which the disclosing entity has a five
15 percent (5%) or more interest, the corporation tax identification number must be
16 disclosed.
(3) For individuals or corporations with ownership or control interest in any
17 subcontractor in which the disclosing entity has a five percent (5%) or more interest,
18 the disclosure of familial relationship is required.
19 (4) For individuals with five percent (5%) or more direct or indirect ownership
20 interest of a disclosing entity, the individual shall provide evidence of completion of a
21 criminal background check, including fingerprinting, if required by law, prior to
execution of Contract. (42 C.F.R. § 455.434)
22
(B) Disclosures Related to Business Transactions:
23 (1) The ownership of any subcontractor with whom Contractor has had business
24 transactions totaling more than $25,000 during the 12-month period ending on the
25 date of the request.
26 (2) Any significant business transactions between Contractor and any wholly
owned supplier, or between Contractor and any subcontractor, during the 5-year
27
period ending on the date of the request. (42 C.F.R. § 455.105(b).)
28 (C) Disclosures Related to Persons Convicted of Crimes:
35
1 (1) The identity of any person who has an ownership or control interest in the
2 provider or is an agent or managing employee of the provider who has been
3 convicted of a criminal offense related to that person's involvement in any program
under the Medicare, Medicaid, or the Title XXI services program since the inception
4
of those programs. (42 C.F.R. § 455.106.)
5 (2) County shall terminate the enrollment of Contractor if any person with five
6 percent (5%) or greater direct or indirect ownership interest in the disclosing entity
7 has been convicted of a criminal offense related to the person's involvement with
8 Medicare, Medicaid, or Title XXI program in the last 10 years.
9 21.3 Contractor must provide disclosure upon execution of Contract, extension for
10 renewal, and within 35 days after any change in Contractor ownership or upon request of
11 County. County may refuse to enter into an agreement or terminate an existing agreement with
12 Contractor if Contractor fails to disclose ownership and control interest information, information
13 related to business transactions and information on persons convicted of crimes, or if Contractor
14 did not fully and accurately make the disclosure as required.
15 21.4 Contractor must provide the County with written disclosure of any prohibited
16 affiliations under 42 C.F.R. § 438.610. Contractor must not employ or subcontract with providers
17 or have other relationships with providers Excluded from participation in Federal Health Care
18 Programs, including Medi-Cal/Medicaid or procurement activities, as set forth in 42 C.F.R.
19 §438.610.
20 21.5 Reporting. Submissions shall be scanned pdf copies and are to be sent via email to
21 DBHContractedServices@fresnocountyca.gov. County may deny enrollment or terminate this
22 Agreement where any person with five (5) percent or greater direct or indirect ownership interest
23 in Contractor has been convicted of a criminal offense related to that person's involvement with
24 the Medicare, Medicaid, or Title XXI program in the last ten (10) years. County may terminate
25 this Agreement where any person with five (5) percent or greater direct or indirect ownership
26 interest in the Contractor did not submit timely and accurate information and cooperate with any
27 screening method required in CFR, Title 42, Section 455.416.
28 1H
36
1 Article 22
2 Disclosure of Criminal History and Civil Actions
3 22.1 Applicability. Contractor is required to disclose if any of the following conditions
4 apply to them, their owners, officers, corporate managers, or partners (hereinafter collectively
5 referred to as "Contractor"):
6 (A) Within the three (3) year period preceding the Agreement award, they have been
7 convicted of, or had a civil judgment tendered against them for:
8 (1) Fraud or criminal offense in connection with obtaining, attempting to obtain,
9 or performing a public (federal, state, or local) transaction or contract under a public
10 transaction;
11 (2) Violation of a federal or state antitrust statute;
12 (3) Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
13 or
14 (4) False statements or receipt of stolen property.
15 (B) Within a three (3) year period preceding their Agreement award, they have had a
16 public transaction (federal, state, or local) terminated for cause or default.
17 22.2 Duty to Disclose. Disclosure of the above information will not automatically
18 eliminate Contractor from further business consideration. The information will be considered as
19 part of the determination of whether to continue and/or renew this Agreement and any additional
20 information or explanation that Contractor elects to submit with the disclosed information will be
21 considered. If it is later determined that the Contractor failed to disclose required information,
22 any contract awarded to such Contractor may be immediately voided and terminated for
23 material failure to comply with the terms and conditions of the award.
24 Contractor must sign a "Certification Regarding Debarment, Suspension, and Other
25 Responsible Matters— Primary Covered Transactions" in the form set forth in Exhibit M attached
26 hereto and by this reference incorporated herein. Additionally, Contractor must immediately
27 advise the County in writing if, during the term of the Agreement: (1) Contractor becomes
28 suspended, debarred, excluded or ineligible for participation in Federal or State funded
37
1 programs or from receiving federal funds as listed in the excluded parties list system
2 (http://www.epls.gov); or (2) any of the above listed conditions become applicable to Contractor.
3 Contractor shall indemnify, defend, and hold County harmless for any loss or damage resulting
4 from a conviction, debarment, exclusion, ineligibility, or other matter listed in the signed
5 Certification Regarding Debarment, Suspension, and Other Responsibility Matters.
6 Article 23
7 Cultural and Linguistic Competency
8 23.1 General.All services, policies and procedures must be culturally and linguistically
9 appropriate. Contractor must participate in the implementation of the most recent Cultural
10 Competency Plan for the County and shall adhere to all cultural competency standards and
11 requirements. Contractor shall participate in the County's efforts to promote the delivery of
12 services in a culturally competent and equitable manner to all individuals, including those with
13 limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and
14 regardless of gender, sexual orientation, or gender identity including active participation in the
15 County's Diversity, Equity and Inclusion Committee.
16 23.2 Policies and Procedures. Contractor shall comply with requirements of policies and
17 procedures for ensuring access and appropriate use of trained interpreters and material
18 translation services for all limited and/or no English proficient beneficiaries, including, but not
19 limited to, assessing the cultural and linguistic needs of the beneficiaries, training of staff on the
20 policies and procedures, and monitoring its language assistance program. Contractor's policies
21 and procedures shall ensure compliance of any subcontracted providers with these
22 requirements.
23 23.3 Interpreter Services. Contractor shall notify its beneficiaries that oral interpretation
24 is available for any language and written translation is available in prevalent languages and that
25 auxiliary aids and services are available upon request, at no cost and in a timely manner for
26 limited and/or no English proficient beneficiaries and/or beneficiaries with disabilities.
27 Contractor shall avoid relying on an adult or minor child accompanying the beneficiary to
28 interpret or facilitate communication; however, if the beneficiary refuses language assistance
38
1 services, the Contractor must document the offer, refusal, and justification in the beneficiary's
2 file.
3 23.4 Interpreter Qualifications. Contractor shall ensure that employees, agents,
4 subcontractors, and/or partners who interpret or translate for a beneficiary or who directly
5 communicate with a beneficiary in a language other than English (1) have completed annual
6 training provided by County at no cost to Contractor; (2) have demonstrated proficiency in the
7 beneficiary's language; (3) can effectively communicate any specialized terms and concepts
8 specific to Contractor's services; and (4) adheres to generally accepted interpreter ethic
9 principles. As requested by County, Contractor shall identify all who interpret for or provide
10 direct communication to any program beneficiary in a language other than English and identify
11 when the Contractor last monitored the interpreter for language competence.
12 23.5 CLAS Standards. Contractor shall submit to County for approval, within ninety (90)
13 days from date of contract execution, Contractor's plan to address all fifteen (15) National
14 Standards for Culturally and Linguistically Appropriate Service (CLAS), as published by the
15 Office of Minority Health and as set forth in Exhibit N "National Standards on Culturally and
16 Linguistically Appropriate Services", attached hereto and incorporated herein by reference and
17 made part of this Agreement. As the CLAS standards are updated, Contractor's plan must be
18 updated accordingly. As requested by County, Contractor shall be responsible for conducting
19 an annual CLAS self-assessment and providing the results of the self-assessment to the
20 County. The annual CLAS self-assessment instruments shall be reviewed by the County and
21 revised as necessary to meet the approval of the County.
22 23.6 Training Requirements. Cultural competency training for Contractor staff should be
23 substantively integrated into health professions education and training at all levels, both
24 academically and functionally, including core curriculum, professional licensure, and continuing
25 professional development programs. As requested by County, Contractor shall report on the
26 completion of cultural competency trainings to ensure direct service providers are completing a
27 minimum of twelve (12) hours of annual cultural competency training.
28
39
1 23.7 Continuing Cultural Competence. Contractor shall create and sustain a forum that
2 includes staff at all agency levels to discuss cultural competence. Contractor shall designate a
3 representative from Contractor's team to attend County's Diversity, Equity and Inclusion
4 Committee.
5 Article 24
6 General Terms
7 24.1 Modification. Except as provided in Article 7, "Termination and Suspension," this
8 Agreement may not be modified, and no waiver is effective, except by written agreement signed
9 by both parties. The Contractor acknowledges that County employees have no authority to
10 modify this Agreement except as expressly provided in this Agreement.
11 (A) Notwithstanding the above, non-material changes to services, staffing, and
12 responsibilities of the Contractor, as needed, to accommodate changes in the laws
13 relating to service requirements and specialty mental health treatment, may be made
14 with the signed written approval of County's DBH Director, or designee, and Contractor
15 through an amendment approved by County's County Counsel and the County's Auditor-
16 Controller/Treasurer-Tax Collector's Office. Said modifications shall not result in any
17 change to the maximum compensation amount payable to Contractor, as stated herein.
18 (B) In addition, changes to line items and expense category subtotals, as set forth in
19 Exhibit E, that when added together during the term of the agreement do not exceed ten
20 percent (10%) of the total maximum compensation payable to Contractor, may be made
21 with the written approval of Contractor and County's DBH Director or designee. Said
22 modifications shall not result in any change to the maximum compensation amount
23 payable to Contractor, as stated herein.
24 24.2 Non-Assignment. Neither party may assign its rights or delegate its obligations
25 under this Agreement without the prior written consent of the other party.
26 24.3 Governing Law. The laws of the State of California govern all matters arising from
27 or related to this Agreement.
28
40
1 24.4 Jurisdiction and Venue. This Agreement is signed and performed in Fresno
2 County, California. Contractor consents to California jurisdiction for actions arising from or
3 related to this Agreement, and, subject to the Government Claims Act, all such actions must be
4 brought and maintained in Fresno County.
5 24.5 Construction. The final form of this Agreement is the result of the parties' combined
6 efforts. If anything in this Agreement is found by a court of competent jurisdiction to be
7 ambiguous, that ambiguity shall not be resolved by construing the terms of this Agreement
8 against either party.
9 24.6 Days. Unless otherwise specified, "days" means calendar days.
10 24.7 Headings. The headings and section titles in this Agreement are for convenience
11 only and are not part of this Agreement.
12 24.8 Severability. If anything in this Agreement is found by a court of competent
13 jurisdiction to be unlawful or otherwise unenforceable, the balance of this Agreement remains in
14 effect, and the parties shall make best efforts to replace the unlawful or unenforceable part of
15 this Agreement with lawful and enforceable terms intended to accomplish the parties' original
16 intent.
17 24.9 Nondiscrimination. During the performance of this Agreement, the Contractor shall
18 not unlawfully discriminate against any employee or applicant for employment, or recipient of
19 services, because of race, religious creed, color, national origin, ancestry, physical disability,
20 mental disability, medical condition, genetic information, marital status, sex, gender, gender
21 identity, gender expression, age, sexual orientation, military status or veteran status pursuant to
22 all applicable State of California and federal statutes and regulation.
23 Contractor shall take affirmative action to ensure that services to intended Medi-Cal
24 beneficiaries are provided without use of any policy or practice that has the effect of
25 discriminating on the basis of race, color, religion, ancestry, marital status, national origin, ethnic
26 group identification, sex, sexual orientation, gender, gender identity, age, medical condition,
27 genetic information, health status or need for health care services, or mental or physical
28 disability.
41
1 24.10 No Waiver. Payment, waiver, or discharge by the County of any liability or obligation
2 of the Contractor under this Agreement on any one or more occasions is not a waiver of
3 performance of any continuing or other obligation of the Contractor and does not prohibit
4 enforcement by the County of any obligation on any other occasion.
5 24.11 Entire Agreement. This Agreement, including its exhibits, is the entire agreement
6 between the Contractor and the County with respect to the subject matter of this Agreement,
7 and it supersedes all previous negotiations, proposals, commitments, writings, advertisements,
8 publications, and understandings of any nature unless those things are expressly included in
9 this Agreement. If there is any inconsistency between the terms of this Agreement without its
10 exhibits and the terms of the exhibits, then the inconsistency will be resolved by giving
11 precedence first to the terms of this Agreement without its exhibits, and then to the terms of the
12 exhibits.
13 24.12 No Third-Party Beneficiaries. This Agreement does not and is not intended to
14 create any rights or obligations for any person or entity except for the parties.
15 24.13 Authorized Signature. The Contractor represents and warrants to the County that:
16 (A) The Contractor is duly authorized and empowered to sign and perform its
17 obligations under this Agreement.
18 (B) The individual signing this Agreement on behalf of the Contractor is duly
19 authorized to do so and his or her signature on this Agreement legally binds the
20 Contractor to the terms of this Agreement.
21 24.14 Electronic Signatures. The parties agree that this Agreement may be executed by
22 electronic signature as provided in this section.
23 (A) An "electronic signature" means any symbol or process intended by an individual
24 signing this Agreement to represent their signature, including but not limited to (1) a
25 digital signature; (2) a faxed version of an original handwritten signature; or (3) an
26 electronically scanned and transmitted (for example by PDF document) version of an
27 original handwritten signature.
28
42
1 (B) Each electronic signature affixed or attached to this Agreement (1) is deemed
2 equivalent to a valid original handwritten signature of the person signing this Agreement
3 for all purposes, including but not limited to evidentiary proof in any administrative or
4 judicial proceeding, and (2) has the same force and effect as the valid original
5 handwritten signature of that person.
6 (C)The provisions of this section satisfy the requirements of Civil Code section
7 1633.5, subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3,
8 Part 2, Title 2.5, beginning with section 1633.1).
9 (D) Each party using a digital signature represents that it has undertaken and
10 satisfied the requirements of Government Code section 16.5, subdivision (a),
11 paragraphs (1) through (5), and agrees that each other party may rely upon that
12 representation.
13 (E) This Agreement is not conditioned upon the parties conducting the transactions
14 under it by electronic means and either party may sign this Agreement with an original
15 handwritten signature.
16 24.15 Counterparts. This Agreement may be signed in counterparts, each of which is an
17 original, and all of which together constitute this Agreement.
18 [SIGNATURE PAGE FOLLOWS]
19
20
21
22
23
24
25
26
27
28
43
1 The parties are signing this Agreement on the date stated in the introductory clause.
2
Hinds Hospice County of Fresno
5 Eric Klimes, CEO Nathan Magsig, Chairman of the Board of
Supervisors of the County of Fresno
6 2490 W. Shaw Ave
Fresno, CA 93711 Attest:
7 Bernice E. Seidel
Clerk of the Board of Supervisors
8 County of Fresno, State of California
9
By:
10 Aeputy*::Ig�
11
12 For accounting use only:
13 Org No.: 56304776
Account No.: 7295
14 Fund No.: 0001
Subclass No.: 10000
15
16
17
18
19
20
21
22
23
24
25
26
27
28
I
I
44 1
Exhibit A- Page 1 of 8
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
CONTRACT PERIOD: July 1, 2024 — June 30, 2026
With three possible 12-month extensions
AMOUNT: FY 24-25: $257,891
FY 25-26: $266,523
FY 26-27: $275,572
FY 27-28: $284,993
FY 28-29: $293,414
Total: $1,378,393
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 available to all individuals affected by the suicide loss, both adults
and children, and will extend into their workplace and communities.
Exhibit A- Page 2 of 8
C. REFERRALS
Referrals for immediate response would more than likely come from law
enforcement dispatch and the coroner's office.
For individuals that reside in our county and the suicide loss occurred out of county,
the referrals will be from chaplain services, medical providers, community
organizations and/or 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 may also be provided at satellite sites which
may include Reedley and other rural locations. Services will not be provided outside
of Fresno County.
E. HOURS OF OPERATION
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. In-office activities are typically provided Monday —
Friday from 8:OOAM to 5:OOPM, but the schedule may be changed to meet the needs
of loss survivors.
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.
Exhibit A- Page 3 of 8
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
Three (3) therapy sessions shall be made available to survivor. Sessions are
free of charge and conducted by clinicians. Evidence-based therapeutic
intervention practices will be used which may include Eye Movement
Desensitization and Reprocessing (EMDR) and Flash Therapy.
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 survivors 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. Survivors Retreat - LOSS clients together for a weekend of therapy and
healing. The retreat will be offered twice a year.
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.
e. Moms 2 Moms — This group meets every other month, providing support and
encouragement to moms who have lost a child to suicide.
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. Four (4)
trainings will be offered each year.
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, survivor's retreat, 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.
Exhibit A- Page 4 of 8
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 E,
Budget Summary.
2. Additions, 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 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. Diversity, Equity, and Inclusion
d. Suicide Prevention Education
4. 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.
5. Contractor shall provide support to the volunteer survivors as well as staff on a
monthly basis.
6. 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.
Exhibit A- Page 5 of 8
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 (https:Hmhsoac.ca.gov/wp-content/uploads/PEI-
Regulations As Of July-2018.pdf).
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 measurable 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.
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.
Exhibit A- Page 6 of 8
Examples of indicators include: Direct staff cost per person served, amount of
time it takes to achieve an outcome, gain in scores per days of service,
service hours per person achieving some positive outcome, total budget
(actual cost) per person served, length of stay and direct service hours of
clinical and medical staff.
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 1 st 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.
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. Conduct four Question, Persuade, and Refer (QPR) trainings a year.
b. The LOSS Team will respond to 80% of active on-scene suicide referrals.
Exhibit A- Page 7 of 8
c. 80% of individuals accessing therapy sessions will have a decrease in
distressing symptoms related to the traumatic experience of the loss, as
measured by Impact of Event Scale (pre and post).
d. 80% of individuals will report satisfaction with grief support services provided
by the LOSS Team, as measured by client survey. (Survey is administered
after 13 months of bereavement mailings).
e. 80% of individuals will demonstrate increased awareness of coping skills and
strategies to mitigate the impacts of grief, as measured by support group
survey.
2. Data Tracking
a. Total number of unduplicated individuals who engaged in services.
b. Total number of unduplicated individuals who enter counseling 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 three
sessions offered.
3. Data Collection
a. Contractor will attempt to collect the following demographics from individuals
served:
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
A. Suicide Loss History
xii. Address
xiii. Referrals for crisis intervention due to safety concerns
xiv. Mode of death
Exhibit A- Page 8 of 8
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.
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.
Exhibit B - Page 1 of 18
BEHAVIORAL 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 Plan
(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 B - Page 2 of 18
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 B - Page 3 of 18
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
Exhibit B - Page 4 of 18
the California Department of Industrial Relations website located at
www.dir.ca.gov, and Public Contract Code Section 6108.
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.
Exhibit B - Page 5 of 18
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)
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.
Exhibit B - Page 6 of 18
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.
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 B - Page 7 of 18
CALIFORNIA ADVANCING AND INNOVATING MEDI-CAL (CAL-AIM)
REQUIREMENTS
1. SERVICES AND ACCESS PROVISIONS
a. CERTIFICATION OF ELIGIBILITY
i. Contractor will, in cooperation with County, comply with Section
14705.5 of California Welfare and Institutions Code to obtain a
certification of an individual's eligibility for Specialty Mental Health
Services (SMHS) under Medi-Cal.
b. ACCESS TO SPECIALTY MENTAL HEALTH SERVICES
i. In collaboration with the County, Contractor will work to ensure
that individuals to whom the Contractor provides SMHS meet
access criteria, as per Department of Health Care Services
(DHCS) guidance specified in BHIN 21-073. Specifically, the
Contractor will ensure that the clinical record for each individual
includes information as a whole indicating that individual's
presentation and needs are aligned with the criteria applicable to
their age at the time of service provision as specified below.
ii. For enrolled individuals under 21 years of age, Contractor shall
provide all medically necessary SMHS required pursuant to
Section 1396d(r) of Title 42 of the United States Code. Covered
SMHS shall be provided to enrolled individuals who meet either of
the following criteria, (1) or (II) below. If an individual under age 21
meets the criteria as described in (1) below, the beneficiary meets
criteria to access SMHS; it is not necessary to establish that the
beneficiary also meets the criteria in (b) below.
1. The individual has a condition placing them at high risk for
a mental health disorder due to experience of trauma
evidenced by any of the following: scoring in the high-risk
range under a trauma screening tool approved by DHCS,
involvement in the child welfare system, juvenile justice
involvement, or experiencing homelessness.
OR
2. The individual has at least one of the following:
a. A significant impairment
b. A reasonable probability of significant deterioration
in an important area of life functioning
c. A reasonable probability of not progressing
developmentally as appropriate.
d. A need for SMHS, regardless of presence of
impairment, that are not included within the mental
health benefits that a Medi-Cal Managed Care Plan
(MCP) is required to provide.
AND the individual's condition as described in subparagraph
(11 a-d) above is due to one of the following:
Exhibit B - Page 8 of 18
a. A diagnosed mental health disorder, according to
the criteria in the current editions of the Diagnostic
and Statistical Manual of Mental Disorders (DSM)
and the International Classification of Diseases and
Related Health Problems (ICD).
b. A suspected mental health disorder that has not yet
been diagnosed.
c. Significant trauma placing the individual at risk of a
future mental health condition, based on the
assessment of a licensed mental health
professional.
iii. For individuals 21 years of age or older, Contractor shall provide
covered SMHS for clients who meet both of the following criteria,
(a) and (b) below:
1. The individual has one or both of the following:
a. Significant impairment, where impairment is defined
as distress, disability, or dysfunction in social,
occupational, or other important activities.
b. A reasonable probability of significant deterioration
in an important area of life functioning.
2. The individual's condition as described in paragraph (a) is
due to either of the following:
a. A diagnosed mental health disorder, according to
the criteria in the current editions of the DSM and
ICD.
b. A suspected mental disorder that has not yet been
diagnosed.
ADDITIONAL CLARIFICATIONS
Criteria
A clinically appropriate and covered mental health
prevention, screening, assessment, treatment, or recovery
service listed within Exhibit A of this Agreement can be
provided and submitted to the County for reimbursement
under any of the following circumstances:
The services were provided prior to determining a
diagnosis, including clinically appropriate and
covered services provided during the assessment
process;
The service was not included in an individual
treatment plan; or
The individual had a co-occurring substance use
disorder.
Diagnosis Not a Prerequisite
Per BHIN 21-073, a mental health diagnosis is not a
prerequisite for access to covered SMHS. This does not
eliminate the requirement that all Medi-Cal claims,
including SMHS claims, include a current Centers fo
Exhibit B - Page 9 of 18
Medicare & Medicaid Services (CMS) approved ICD
diagnosis code
d. MEDICAL NECESSITY
i. Contractor will ensure that services provided are medically
necessary in compliance with BHIN 21-073 and pursuant to
Welfare and Institutions Code section 14184.402(a). Services
provided to a client must be medically necessary and clinically
appropriate to address the individual's presenting condition.
Documentation in each individual's chart as a whole will
demonstrate medical necessity as defined below, based on the
client's age at the time of service provision.
ii. For individuals 21 years of age or older, a service is "medically
necessary" or a "medical necessity" when it is reasonable and
necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain as set forth in Welfare and
Institutions Code section 14059.5.
iii. For individuals under 21 years of age, a service is "medically
necessary" or a "medical necessity" if the service meets the
standards set forth in Section 1396d(r)(5) of Title 42 of the United
States Code.
e. COORDINATION OF CARE
i. Contractor shall ensure that all care, treatment and services
provided pursuant to this Agreement are coordinated among all
providers who are serving the individual, including all other SMHS
providers, as well as providers of Non-Specialty Mental Health
Services (NSMHS), substance use disorder treatment services,
physical health services, dental services, regional center services
and all other services as applicable to ensure a client-centered
and whole-person approach to services.
ii. Contractor shall ensure that care coordination activities support
the monitoring and treatment of comorbid substance use disorder
and/or health conditions.
iii. Contractor shall include in care coordination activities efforts to
connect, refer and link individual s to community-based services
and supports, including but not limited to educational, social,
prevocational, vocational, housing, nutritional, criminal justice,
transportation, childcare, child development, family/marriage
education, cultural sources, and mutual aid support groups.
iv. Contractor shall engage in care coordination activities beginning
at intake and throughout the treatment and discharge planning
processes.
v. To facilitate care coordination, Contractor will request a HIPAA
and California law compliant client authorization to share the
individual's information with and among all other providers
involved in the individual's care, in satisfaction of state and federal
privacy laws and regulations.
f. CO-OCCURRING TREATMENT AND NO WRONG DOOR
Exhibit B - Page 10 of 18
i. Per BHIN 22-011, Specialty and Non-Specialty Mental Health
Services can be provided concurrently, if those services are
clinically appropriate, coordinated, and not duplicative. When a
client meets criteria for both NSMHS and SMHS, the individual
should receive services based on individual clinical need and
established therapeutic relationships. Clinically appropriate and
covered SMHS can also be provided when the individual has a co-
occurring mental health condition and substance use disorder.
ii. Under this Agreement, Contractor will ensure that individual s
receive timely mental health services without delay. Services are
reimbursable to Contractor by County even when:
1. Services are provided prior to determination of a diagnosis,
during the assessment or prior to determination of whether
SMHS access criteria are met, even if the assessment
ultimately indicates the individual does not meet criteria for
SMHS.
2. If Contractor is serving a individual receiving both SMHS
and NSMHS, Contractor holds responsibility for
documenting coordination of care and ensuring that
services are non-duplicative.
2. AUTHORIZATION AND DOCUMENTATION PROVISIONS
a. SERVICE AUTHORIZATION
i. Contractor will collaborate with County to complete authorization
requests in line with County and DHCS policy.
ii. Contractor shall have in place, and follow, written policies and
procedures for completing requests for initial and continuing
authorizations of services, as required by County guidance.
iii. Contractor shall respond to County in a timely manner when
consultation is necessary for County to make appropriate
authorization determinations.
iv. County shall provide Contractor with written notice of authorization
determinations within the timeframes set forth in BHINs 22-016
and 22-017, or any subsequent DHCS notices.
v. Contractor shall alert County when an expedited authorization
decision (no later than 72 hours) is necessary due to an
individual's specific needs and circumstances that could seriously
jeopardize the individual s life or health, or ability to attain,
maintain, or regain maximum function.
b. DOCUMENTATION REQUIREMENTS
i. Contractor will follow all documentation requirements as specified
in Article 4.2-4.8 inclusive in compliance with federal, state and
County requirements.
ii. All Contractor documentation shall be accurate, complete, and
legible, shall list each date of service, and include the face-to-face
time for each service. Contractor shall document travel and
documentation time for each service separately from face-to-face
time and provide this information to County upon request.
Exhibit B - Page 11 of 18
Services must be identified as provided in-person, by telephone,
or by telehealth.
iii. All services shall be documented utilizing County-approved
templates and contain all required elements. Contractor agrees to
satisfy the chart documentation requirements set forth in BHIN 22-
019 and the contract between County and DHCS. Failure to
comply with documentation standards specified in this Article
require corrective action plans.
c. ASSESSMENT
i. Contractor shall ensure that all individuals' medical records
include an assessment of each individual's need for mental health
services.
ii. Contractor will utilize the seven uniform assessment domains and
include other required elements as identified in BHIN 22-019 and
document the assessment in the individual's medical record.
iii. For individual s aged 6 through 20, the Child and Adolescent
Needs and Strengths (CANS), and for individual s aged 3 through
18, the Pediatric Symptom Checklist-35 (PSC-35) tools are
required at intake, every six months during treatment, and at
discharge, as specified in DHCS MHSUDS INs 17-052 and 18-
048.
iv. The time period for providers to complete an initial assessment
and subsequent assessments for SMHS are up to clinical
discretion of County; however, Contractor's providers shall
complete assessments within a reasonable time and in
accordance with generally accepted standards of practice.
d. ICD-10
i. Contractor shall use the criteria set forth in the current edition of
the DSM as the clinical tool to make diagnostic determinations.
ii. Once a DSM diagnosis is determined, the Contractor shall
determine the corresponding mental health diagnosis in the
current edition of ICD. Contractor shall use the ICD diagnosis
code(s)to submit a claim for SMHS to receive reimbursement
from County.
iii. The ICD Tabular List of Diseases and Injuries is maintained by
CMS and may be updated during the term of this Agreement.
Changes to the lists of ICD diagnoses do not require an
amendment to this Agreement, and County may implement these
changes as provided by CMS
e. PROBLEM LIST
i. Contractor will create and maintain a Problem List for each
individual served under this Agreement. The problem list is a list of
symptoms, conditions, diagnoses, and/or risk factors identified
through assessment, psychiatric diagnostic evaluation, crisis
encounters, or other types of service encounters.
ii. Contractor must document a problem list that adheres to industry
standards utilizing at minimum current SNOMED International,
Exhibit B - Page 12 of 18
Systematized Nomenclature of Medicine Clinical Terms
(SNOMED CT®) U.S. Edition, September 2022 Release, and ICD-
10-CM 2023.
iii. A problem identified during a service encounter may be addressed
by the service provider during that service encounter and
subsequently added to the problem list.
iv. The problem list shall include, but is not limited to, all elements
specified in BHIN 22-019.
v. County does not require the problem list to be updated within a
specific timeframe or have a requirement about how frequently the
problem list should be updated after a problem has initially been
added. However, Contractor shall update the problem list within a
reasonable time such that the problem list reflects the current
issues facing the client, in accordance with generally accepted
standards of practice and in specific circumstances specified in
BHIN 22-019.
f. TREATMENT AND CARE PLANS
i. Contractor is not required to complete treatment or care plans for
clients under this Agreement, except in the circumstances
specified in BHIN 22-019 and additional guidance from DHCS that
may follow after execution of this Agreement.
g. PROGRESS NOTES
i. Contractor shall create progress notes for the provision of all
SMHS services provided under this Agreement.
ii. Each progress note shall provide sufficient detail to support the
service code selected for the service type as indicated by the
service code description.
iii. Progress notes shall include all elements specified in BHIN 22-
019, whether the note be for an individual or a group service.
iv. Contractor shall complete progress notes within three business
days of providing a service, with the exception of notes for crisis
services, which shall be completed within 24 hours.
v. Providers shall complete a daily progress note for services that
are billed on a daily basis, such as residential and day treatment
services, if applicable.
h. TRANSITION OF CARE TOOL
i. Contractor shall use a Transition of Care Tool for any individual
whose existing services will be transferred from Contractor to an
Medi-Cal Managed Care Plan (MCP) provider or when NSMHS
will be added to the existing mental health treatment provided by
Contractor, as specified in BHIN 22-065, in order to ensure
continuity of care.
ii. Determinations to transition care or add services from an MCP
shall be made in alignment with County policies and via a person-
centered, shared decision-making process.
iii. Contractor may directly use the DHCS-provided Transition of Care
Tool, found at https://www.dhcs.ca.gov/Pages/Screening-and-
Exhibit B - Page 13 of 18
Transition-of-Care-Tools-for-Medi-Cal-Mental-Health-
Services.aspx, or obtain a copy of that tool provided by the
County. Contractor may create the Transition of Care Tool in its
Electronic Health Record (EHR). However, the contents of the
Transition of Care Tool, including the specific wording and order of
fields, shall remain identical to the DHCS provided form. The only
exception to this requirement is when the tool is translated into
languages other than English.
i. TELEHEALTH
i. Contractor may use telehealth, when it deems clinically
appropriate, as a mode of delivering behavioral health services in
accordance with all applicable County, state, and federal
requirements, including those related to privacy/security,
efficiency, and standards of care. Such services will conform to
the definitions and meet the requirements included in the Medi-Cal
Provider Manual: Telehealth, available in the DHCS Telehealth
Resources page at:
httos://www.dhcs.ca.gov/i)rovgovparUPages/Telehealth Resources
.aspx.
ii. All telehealth equipment and service locations must ensure that
client confidentiality is maintained.
iii. Licensed providers and staff may provide services via telephone
and telehealth as long as the service is within their scope of
practice.
iv. Medical records for individuals served by Contractor under this
Agreement must include documentation of written or verbal
consent for telehealth or telephone services if such services are
provided by Contractor. Such consent must be obtained at least
once prior to initiating applicable health care services and consent
must include all elements as specified in BHIN 22-019.
v. County may at any time audit Contractor's telehealth practices,
and Contractor must allow access to all materials needed to
adequately monitor Contractor's adherence to telehealth
standards and requirements.
3. CLIENT PROTECTIONS
a. GRIEVANCES, APPEALS AND NOTICES OF ADVERSE BENEFIT
DETERMINATION
i. All grievances (as defined by 42 C.F.R. § 438.400) and complaints
received by Contractor must be immediately forwarded to the
County's Managed Care Department or other designated persons
via a secure method (e.g., encrypted email or by fax) to allow
ample time for the Managed Care staff to acknowledge receipt of
the grievance and complaints and issue appropriate responses.
ii. Contractor shall not discourage the filing of grievances and
individual s do not need to use the term "grievance" for a
complaint to be captured as an expression of dissatisfaction and,
therefore, a grievance.
Exhibit B - Page 14 of 18
iii. Aligned with MHSUDS IN 18-010E and 42 C.F.R. §438.404, the
appropriate and delegated Notice of Adverse Benefit
Determination (NOABD) must be issued by Contractor within the
specified timeframes using the template provided by the County.
iv. NOABDs must be issued to individuals anytime the Contractor has
made or intends to make an adverse benefit determination that
includes the reduction, suspension, or termination of a previously
authorized service and/or the failure to provide services in a timely
manner. The notice must have a clear and concise explanation of
the reason(s) for the decision as established by DHCS and the
County. The Contractor must inform the County immediately after
issuing a NOABD.
v. Procedures and timeframes for responding to grievances, issuing
and responding to adverse benefit determinations, appeals, and
state hearings must be followed as per 42 C.F.R., Part 438,
Subpart F (42 C.F.R. §§ 438.400 —438.424).
vi. Contractor must provide individuals any reasonable assistance in
completing forms and taking other procedural steps related to a
grievance or appeal such as auxiliary aids and interpreter
services.
vii. Contractor must maintain records of grievances and appeals and
must review the information as part of its ongoing monitoring
procedures. The record must be accurately maintained in a
manner accessible to the County and available upon request to
DHCS.
b. Advanced Directives
i. Contractor must comply with all County policies and procedures
regarding Advanced Directives in compliance with the
requirements of 42 C.F.R. §§422.128 and 438.6(i) (1), (3) and (4).
c. Continuity of Care
i. Contractor shall follow the County's continuity of care policy that is
in accordance with applicable state and federal regulations,
MHSUDS IN 18-059 and any BHINs issued by DHCS for parity in
mental health and substance use disorder benefits subsequent to
the effective date of this Agreement (42 C.F.R. §438.62(b)(1)-(2).)
4. QUALITY IMPROVEMENT PROGRAM
a. QUALITY IMPROVEMENT ACTIVITIES AND PARTICIPATION
i. Contractor shall implement mechanisms to assess person
served/family satisfaction based on County's guidance. The
Contractor shall assess individual/family satisfaction by:
1. Surveying person served/family satisfaction with the
Contractor's services at least annually.
2. Evaluating person served's grievances, appeals and State
Hearings at least annually.
3. Evaluating requests to change persons providing services
at least annually.
Exhibit B - Page 15 of 18
4. Informing the County and individuals of the results of
client/family satisfaction activities.
ii. Contractor, if applicable, shall implement mechanisms to monitor
the safety and effectiveness of medication practices. This
mechanism shall be under the supervision of a person licensed to
prescribe or dispense prescription drugs, at least annually and as
required by DBH.
iii. Contractor shall implement mechanisms to monitor appropriate
and timely intervention of occurrences that raise quality of care
concerns. The Contractor shall take appropriate follow-up action
when such an occurrence is identified. The results of the
intervention shall be evaluated by the Contractor at least annually
and shared with the County.
iv. Contractor shall assist County, as needed, with the development
and implementation of Corrective Action Plans.
v. Contractor shall collaborate with County to create a QI Work Plan
with documented annual evaluations and documented revisions
as needed. The QI Work Plan shall evaluate the impact and
effectiveness of its quality assessment and performance
improvement program.
vi. Contractor shall attend and participate in the County's Quality
Improvement Committee (QIC) to recommend policy decisions,
review and evaluate results of QI activities, including PIPs,
institute needed QI actions, and ensure follow-up of QI processes.
Contractor shall ensure that there is active participation by the
Contractor's practitioners and providers in the QIC.
vii. Contractor shall participate, as required, in annual, independent
external quality reviews (EQR) of the quality, timeliness, and
access to the services covered under this Contract, which are
conducted pursuant to Subpart E of Part 438 of the Code of
Federal Regulations. (42 C.F.R. §§ 438.350(a) and 438.320)
TIMELY ACCESS
Timely access standards include:
Contractor must have hours of operation during which
services are provided to Medi-Cal individuals that are no
less than the hours of operation during which the provider
offers services to non-Medi-Cal individual s. If the
Contractor's provider only serves Medi-Cal clients, the
provider must provide hours of operation comparable to
the hours the provider makes available for Medi-Cal
services that are not covered by the Agreement or another
County.
2. Appointments data, including wait times for requested
services, must be recorded and tracked by Contractor, and
submitted to the County on a monthly basis in a format
specified by the County. Appointments' data should be
submitted to the County's Quality Management
Department or other designated persons.
Exhibit B - Page 16 of 18
3. Urgent care appointments for services that do not require
prior authorization must be provided to individual s within
48 hours of a request. Urgent appointments for services
that do require prior authorization must be provided to
clients within 96 hours of request.
4. Non-urgent non-psychiatry mental health services,
including, but not limited to Assessment, Targeted Case
Management, and Individual and Group Therapy
appointments (for both adult and children/youth) must be
made available to Medi-Cal individuals within 10 business
days from the date the individual or a provider acting on
behalf of the individual, requests an appointment for a
medically necessary service. Non-urgent psychiatry
appointments (for both adult and children/youth) must be
made available to Medi-Cal individual s within 15 business
days from the date the client or a provider acting on behalf
of the individual, requests an appointment for a medically
necessary service.
5. Applicable appointment time standards may be extended if
the referring or treating provider has determined and noted
in the individual's record that a longer waiting period will
not have a detrimental impact on the health of the
individual.
6. Periodic office visits to monitor and treat mental health
conditions may be scheduled in advance consistent with
professionally recognized standards of practice as
determined by the treating licensed mental health provider
acting within the scope of their practice.
c. PROVIDER APPLICATION AND VALIDATION FOR ENROLLMENT
(PAVE)
i. Contractor shall ensure that all of its required clinical staff, who
are rendering SMHS to Medi-Cal individuals on behalf of
Contractor, are registered through DHCS' Provider Application
and Validation for Enrollment (PAVE) portal, pursuant to BHIN 20-
071 requirements, the 21st Century Cures Act and the CMS
Medicaid and Children's Health Insurance Program (CHIP)
Managed Care Final Rule.
ii. SMHS licensed individuals required to enroll via the "Ordering,
Referring and Prescribing" (ORP) PAVE enrollment pathway (i.e.
PAVE application package) available through the DHCS PED
Pave Portal, include: Licensed Clinical Social Worker (LCSW),
Licensed Marriage and Family Therapist (LMFT), Licensed
Professional Clinical Counselor (LPCC), Psychologist, Licensed
Educational Psychologist, Physician (MD and DO), Physician
Assistant, Registered Pharmacist/Pharmacist, Certified
Pediatric/Family Nurse Practitioner, Nurse Practitioner,
Occupational Therapist, and Speech-Language Pathologist.
Interns, trainees, and associates are not eligible for enrollment.
Exhibit B - Page 17 of 18
d. PHYSICIAN INCENTIVE PLAN
i. If Contractor wants to institute a Physician Incentive Plan,
Contractor shall submit the proposed plan to the County which will
in turn submit the Plan to the State for approval, in accordance
with the provisions of 42 C.F.R. § 438.6(c).
5. DATA, PRIVACY AND SECURITY REQUIREMENTS
ELECTRONIC PRIVACY AND SECURITY
Contractor shall have a secure email system and send any email
containing PII or PHI in a secure and encrypted manner.
Contractor's email transmissions shall display a warning banner
stating that data is confidential, systems activities are monitored
and logged for administrative and security purposes, systems use
is for authorized users only, and that users are directed to log off
the system if they do not agree with these requirements.
Contractor shall institute compliant password management
policies and procedures, which shall include but not be limited to
procedures for creating, changing, and safeguarding passwords.
Contractor shall establish guidelines for creating passwords and
ensuring that passwords expire and are changed at least once
every 90 days.
Any Electronic Health Records (EHRs) maintained by Contractor
that contain PHI or PII for individuals served through this
Agreement shall contain a warning banner regarding the PHI or
PII contained within the EHR. Contractors that utilize an EHR shall
maintain all parts of the clinical record that are not stored in the
EHR, including but not limited to the following examples of client
signed documents: discharge plans, informing materials, and
health questionnaire.
Contractor entering data into any County electronic systems shall
ensure that staff are trained to enter and maintain data within this
system.
6. PROGRAM INTEGRITY
Credentialing and Re-credentialing of Providers
Contractor shall ensure that all of their network providers
delivering covered services, sign and date an attestation
statement on a form provided by County, in which each provider
attests to the following:
Any limitations or inabilities that affect the provider's ability
to perform any of the position's essential functions, with or
without accommodation;
2. A history of loss of license or felony convictions;
3. A history of loss or limitation of privileges or disciplinary
activity;
4. A lack of present illegal drug use; and
. The application's accuracy and completeness
Exhibit B - Page 18 of 18
ii. Contractor must file and keep track of attestation statements,
credentialing applications and credentialing status for all of their
providers and must make those available to the County upon
request at any time.
iii. Contractor is required to sign an annual attestation statement at
the time of Agreement renewal in which they will attest that they
will follow County's Credentialing Policy and MHSUDS IN 18-019
and ensure that all of their rendering providers are credentialed as
per established guidelines.
coU,��.t.
Exhibit C- Page 1 of 4
Department of
o� 185 Q Behavioral Health
FRf PPG 1.3.14 V#: 2
Section: DBH Policies & Procedures, Mental Health, Substance Use Disorder
Effective Date: 07/09/2021 Revised Date: 01/10/2024
Policy Title: Guiding Principles of Care Delivery
Approved by:Joseph Rangel (Behavioral Health Division Manager), Lesby Flores (Licensed Deputy Director of
Behavioral Health), Stacy VanBruggen (Licensed Behavioral Health Division Manager), Susan Holt (Director of
Behavioral Health)
POLICY: The DBH Guiding Principles of Care Delivery define and guide our
Behavioral Health System of Care. We expect 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.
PURPOSE: The principles provide the clinical framework that influences decision-
making in all aspects of care delivery including program design and
implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
REFERENCE: N/A
DEFINITIONS: Quadruple Aim — (1) deliver quality care, (2) maximize resources while
focusing on efficiency, (3) provide an excellent care experience, and (4)
promote workforce well-being.
PROCEDURE:
I. Principle One — Timely Access & Integrated Services
A. Persons-served are connected with services in a manner that is efficient and
effective.
B. Collaborative care coordination occurs across agencies, plans for care are
integrated, and whole person care considers all life domains such as physical
health, education, employment, housing, spirituality and other social determinant
of health.
C. Barriers to access and treatment are identified and addressed.
D. Excellent customer service ensures persons served are transitioned from one
point of care to another without disruption of care.
II. Principle Two — Strengths-Based
A. Positive change occurs within the context of genuine trusting relationships.
MISSION STATEMENT
DBH,in partnership with our diverse communities,is dedicated to providing quality,culturally responsive,behavioral health services to promote
wellness,recovery,and resiliency for individuals and families in our community.
0812021
Exhibit C- Page 2 of 4
Section: DBH Policies& Procedures, Mental Health,Substance Use
Disorder
PPG 1.3.14 V#:2
Policy Title:Guiding Principles of Care Delivery
B. Individuals, families, and communities are resourceful and resilient in the way
they solve problems.
C. Hope and optimism are created through the identification of, and focus on, the
unique abilities of persons served.
III. Principle Three — Person-Driven and Family-Driven
A. Self-determination and self-direction are the foundations for recovery.
B. Persons served optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences.
C. Providers contribute clinical expertise, provide options, and support persons
served in informed decision making, developing goals and objectives, and
identifying pathways to recovery.
D. Persons served partner with their provider(s) in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive.
IV. Principle Four— Inclusive of Natural Supports
A. The person served identifies and defines family and other natural supports to be
included in care.
B. Persons served speak for themselves.
C. 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.
D. Providers assist persons served in developing and utilizing natural supports.
V. Principle Five — Clinical Significance and Evidence Based Practices (EBP)
A. Services are effective, resulting in a noticeable, measurable change in daily life.
B. Clinical practice is informed by best available research evidence, best clinical
expertise, and the values and preferences of those we serve.
C. Other clinically and culturally significant interventions such as innovative,
promising, and emerging practices are embraced.
VI. Principle Six — Culturally Responsive
A. Values, traditions, and beliefs specific to a person served's culture(s) are valued
and leveraged to support the their wellness, resilience, and recovery.
B. Services are culturally grounded, congruent, and personalized to reflect the
unique cultural experience of each person served.
2 1 P a g e
Exhibit C- Page 3 of 4
Section: DBH Policies& Procedures, Mental Health,Substance Use
Disorder
PPG 1.3.14 V#:2
Policy Title:Guiding Principles of Care Delivery
C. Providers exhibit the highest level of cultural humility and responsiveness to the
self-identified culture(s) of the person or family served in striving to achieve the
greatest equity in care delivery.
VII. Principle Seven — Trauma-informed and Trauma-Responsive
A. The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood.
B. Signs and symptoms of trauma in persons served, team members, and others
are recognized and persons served receive trauma-informed responses.
C. Physical, psychological, and emotional safety for persons served and treatment
team members is emphasized.
VIII. Principle Eight — Co-Occurring Capable
A. 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.
B. Treatment of mental health and substance use disorders are integrated. A
provider or team may deliver treatment for mental health and substance use
disorders at the same time.
IX. Principle Nine — Stages of Change, Motivation, and Harm Reduction
A. Interventions are motivation-based and adapted to the person served's stage of
change.
B. Progression through stages of change is supported through positive working
relationships and alliances that are motivating.
C. Providers support persons served to develop strategies aimed at reducing
negative outcomes of substance misuse through a harm reduction approach.
D. Each person served defines their own recovery and recovers at their own pace
when provided with sufficient dignity, time, and support.
X. Principle Ten — Continuous Quality Improvement and Outcomes-Driven
A. Individual and program outcomes are collected and evaluated for quality and
efficacy.
B. Strategies are implemented to achieve a system of continuous quality
improvement and improved performance outcomes.
C. Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models.
31
Exhibit C- Page 4 of 4
Section: DBH Policies& Procedures, Mental Health,Substance Use
Disorder
PPG 1.3.14 V#:2
Policy Title:Guiding Principles of Care Delivery
XI. Principle Eleven — Health and Wellness Promotion, Illness and Harm Prevention,
and Stigma Reduction
A. The rights of all persons served are respected and persons served are treated
with dignity.
B. Behavioral health is recognized as essential for person served and community
well-being.
C. Promotion of health and wellness is interwoven throughout all aspects of DBH
services.
D. Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels.
E. Stigma is actively reduced by promoting awareness and accountability through
creating positive change in attitudes, beliefs, practices, and policies within all
systems.
F. The vision of health and well-being for our community is continually addressed
through collaborations between providers, persons served, families, and
community members.
4 1 P a g e
Exhibit D - Page 1 of 6
coU Department of Behavioral Health
Policy and Procedure Guide
0� 1$50
FRES PPG 1.2.7
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)
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.
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 3128116
11
Exhibit D - Page 2 of 6
coU Department of Behavioral Health
Policy and Procedure Guide
O 1856 O
FRES' Section: Mental Health Effective Date:05/30/2017 PPG 1.2.7
Policy Title: Performance Outcome Measures
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.
2 1 P a g e
Exhibit D - Page 3 of 6
coU Department of Behavioral Health
Policy and Procedure Guide
O 1856 O
FRES' Section: Mental Health Effective Date:05/30/2017 PPG 1.2.7
Policy Title: Performance Outcome Measures
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)
3 1 P a g e
Exhibit D - Page 4 of 6
FRESNO COUNTY MENTAL HEALTH PLAN OUTCOMES REPORT- Attachment A
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:
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.
Revised May 2018
Exhibit D - Page 5 of 6
FRESNO COUNTY MENTAL HEALTH PLAN OUTCOMES REPORT- Attachment A
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.
•lndividual/Family-Driven,Wellnes s/Recovery/Resiliency Focused Services:adult clients and families ofchildren and youth identify needs and preferences that result in
the most effective services and supports.
•Access to underserved communities:Hstoricallyunserved and underserved coma unities are those groups that either have documented low levels ofaccess and/or use of
mental health services,face barriers to participation in the policy making process in public mental health,have lowrates ofinsurance 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
-Mzst include each of these areas/domains: (1)Effectiveness,(2)Efficiency,(3)Access,(4)Satisfaction&Feedback OfPetsons Served&Stakeholder
-Include the following components for documenting each goal: (1)Indicator, (2)Who Applied,(3)Thr ofNtasure,(4)Data Source,(5)Target Goal Expectancy
Click here to enter text.
DEPARTMENT RECOMMENDATION(S):
Click here to enter text
Revised May 2018
Exhibit D - Page 6 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 E - Page 1 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY)2024-2025
PROGRAM EXPENSES
1000:DIRECT SALARIES&BENEFITS
Direct Employee Salaries
Acct# Administrative Position FTE Admin Program Total
Direct Personnel Admin Salaries Subtotal 0.00 $ - $ -
Acct# Program Position FTE Admin Program Total
1116 Program Director 0.20 $ 28,000 $ 28,000
1117 Program Coordinator 0.80 $ 61,570 $ 61,570
1118 Licensed Clinician 0.20 $ 18,720 $ 18,720
1119 Bereavement Support Clinician 0.30 $ 18,720 $ 18,720
1120 After Hour On-Call Clinicians 2.70 $ 34,740 $ 34,740
1121 After Hour Response Clinicians 0.06 $ 8,400 $ 8,400
1122 Support Group Facilitation 0.04 $ 6,720 $ 6,720
Direct Personnel Program Salaries Subtotal 4.30 $ 176,870 $ 176,870
Admin Program Total
Direct Personnel Salaries Subtotal 4.30 $ - $ 176,870 $ 176,870
Direct Employee Benefits
Acct# Description Admin Program Total
1201 Retirement $ 3,810 $ 3,810
1202 Worker's Compensation - 549 549
1203 Health Insurance - 15,290 15,290
1204 Other(specify)-Life Insurance - 278 1 278
Direct Employee Benefits Subtotal: $ - $ 19,927 $ 19,927
Direct Payroll Taxes&Expenses:
Acct# Description Admin Program Total
1301 OASDI $ - $ - $ -
1302 FICA/MEDICARE - 13,532 13,532
1303 SUI - 354 354
Direct Payroll Taxes&Expenses Subtotal: $ - $ 13,886 $ 13,886
DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total
$ - $ 210,683 $ 210,683
DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program
0%1 1000
Exhibit E - Page 2 of 30
3000: DIRECT OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 2,400
3002 Printing/Postage $ 2,200
3003 Office, Household &Program Supplies $ 2,300
3004 Advertising $ 2,300
3005 Staff Development&Training $ 4,000
3006 Staff Mileage $ 1,600
3007 Subscriptions&Memberships $ 323
3009 Other(specify)-Retreat $ 19,500
3010 Other(specify)- Background Checks $ 900
3011 Other(specify)-Uniforms/Badges $ 500
3012 Other(specify)-Travel $ 1,000
DIRECT OPERATING EXPENSES TOTAL: $ 37,023
4000: DIRECT FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4002 Rent/Lease Building $ 4,125
4005 Security $ 2,160
DIRECT FACILITIES/EQUIPMENT TOTAL: $ 6,285
5000: DIRECT SPECIAL EXPENSES
Acct# I Line Item Description Amount
5004 ITranslation Services $ 1,300
DIRECT SPECIAL EXPENSES TOTAL: $ 1,300
6000: INDIRECT EXPENSES
Acct# Line Item Description Amount
Administrative Overhead
6001 Use this line and only this line for approved indirect cost rate $ -
Administrative Overhead
6003 Accounting/Bookkeeping $ 2,600
INDIRECT EXPENSES TOTAL $ 2,600
INDIRECT COST RATE 1.02%
TOTAL PROGRAM EXPENSES $ 257,891
PROGRAM FUNDING SOURCES
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8302 PEI- Prevention&Early Intervention Suicide Prevention 257,891
MHSA TOTAL $ 257,891
TOTAL PROGRAM FUNDING SOURCES: $ 257,891
NET PROGRAM COST: $ -
Exhibit E - Page 3 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2024-2025
PARTIAL FTE DETAIL
For all positions with FTE's split among multiple programs/contracts the below must be filled
out
Position Contract#/Name/Department/County FTE
Program Director Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Program Coordinator Fresno County LOSS Team 0.80
Other Programs 0.20
Total 1.00
Position Contract#/Name/Department/County FTE
Licensed Clinician Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Bereavement Support Clinician Fresno County LOSS Team 0.30
Other Programs 0.70
Total 1.00
Exhibit E - Page 4 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY)2024-2025 Budget Narrative
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:DIRECT SALARIES&BENEFITS 210,683
Administrative Positions -
Program Positions 176,870
1116 Program Director 28,000 The director is responsible for developing,coordinating,supervising,providing and/
assuring provision of bereavement services to through the Center for Grief and Healing.
Director oversees all aspects of the various bereavement programs and provides
supervision to staff involved in the Program. The Director also provides direct services
to LOSS clients.
0.2 FTE x 140,000 Annual Salary=2800
1117 Program Coordinator 61,570 The Program Coordinator is responsible for coordinating and providing grief support
services,community education and outreach to include supervision of volunteers.
Program Coordinator also responds to LOSS calls that occur during normal business
hours.
0.8 FTE x 76,962 Annual Salary=61,568
1118 Licensed Clinician 18,720 The Licensed Clinician provides support to grieving individuals,couples and families.
Supports may include family counseling sessions and other supports.
0.2 FTE x 93,600 Annual Salary=18,720
1119 Bereavement Support Clinician 18,720 Bereavement Support Clinician will assist with data entry and reporting,bereavement
support phone calls,outreach and education,and administrative duties.
0.3 FTE x 62,400 Annual Salary=18,720
1120 After Hour On-Call Clinicians 34,740 On Call Clinicians take calls 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 responses to LOSS team requests. Clinicians are required
for immediate responses 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 volunteer
and first responders. Rate is$6/hour for non holiday hours and$9/hour for holidays.
350 days x 15 after hours x$6=31,500,plus holidays 15 days x 24 after hours x$9=
3,240,combined cost is$34,740
1121 After Hour Response Clinicians 8,400 The After Hours Response Clinician responds to LOSS calls outside of normal business
hours,providing immediate support and guidance to suicide LOSS survivors;also
conduct debriefing with the on scene volunteers. These are on site attendence. 48
calls @ an average of 2.5 hours/call at an overtime average rate of$70/hour =$8,400
1122 Support Group Facilitation 6,720 Support groups are facilitated by a trained clinician and a total of 45 groups sessions
are held per year at an average cost of$149.33/session. Group sessions are conducted
by a staff clinician. Groups are offered in evenings with overtime rates applicable.
These are conducted by Hinds employees on hourly salary rates;calcuated at OT rate
(two hours for group,group set up,group preparation at average rate of$149.33
covering an average of 2 hours for each session;45 sessions x$149.33/session=
$6,720
Direct Employee Benefits
1201 Retirement 3,810 3%match up to 6%of allowable LOSS contract salary. Salaries for SOSL Program Coord,
Licensed Clinician,CGH Director,&Bereavement Clin Support(participants);(61,568+
18,720+28,000+18,720)x.06/2(to represent 3%match)
1202 Worker's Compensation 549 Starting with 2024 rates based on WC class codes and experience modifiers applied to
allowable LOSS contract salaries. WC rate for Class 8742 is.31%;Total salaries
176,870 x.0031%=$548.30
1203 Health Insurance 15,290 Based on current negotiated rates;prorated over FTE($849.60/month/employee,4
employees with coverage,used FTE count or%of employee to prorate health care
insurance costs over Loss and Other. Participants are SOSL Program Coordinator at.8,
Licensed Clinical at.2,Program Director at.2,and Bereavement Clin Support at.3 FTE.
Then,the monthly cost is annualized by multiplying it by 12. (849.60 x.8)+(849.60 x
.2)+(849.46 x.2)+(849.46 x.3)and the total multiplied by 12=15,290
Exhibit E - Page 5 of 30
PROGRAM EXPENSE
ACCT#j LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1204 Other(specify)-Life Insurance 278 Benefit costs are based on federal/state mandated costs;benefits are based on best
market rates and negotiated each year,proratde per FTE. SOSL Coordinator is at 14.63
with.8=11.70,Licensed Clin is at 17.56 with.2 FTE=3.51, Program Director is at
26.79 at.2 FTE=5.36,,and the Bereavement Clin is at 8.74 with.3 FTE=2.62. The
Support Group Facilitator-no cost associated.Those rates(11.70+3.51+5.36 +2.62)x
12 months=278.35
Direct Payroll Taxes&Expenses: 13,886
1301 CA DI -
1302 FICA/MEDICARE 13,532 7.65%x 176,870.00 LOSS contract salaries;IRS requirement for employer contribution
1303 SUI 354 .002%of LOSS contract allowable wages Of 176,870.00
3000:DIRECT OPERATING EXPENSES 37,023
3001 Telecommunications 2,400 Cell phones,dedicated LOSS landline,laptops and internet purchased and secured for
LOSS team usage. Estimate based on current run rates.
$50 x 4 staff x 12 months=$2400
3002 Printing/Postage 2,200 Postage will be used to mail out bereavement and informational resource packets to
families in our communities. Mailings include invitations to special events. Printing
costs cover flyers,brochures,informational packets and business cards. Estimated
average$183.33 x 12 months=$2200
3003 Office,Household&Program Supplies 2,300 The Program Supply,Office and Household budget will cover suicide grief goods for
children,resources from the American Foundation for Suicide Prevention(AFSP)and
Suicide Awareness Voices of Educatjion(SAVE),and kits containing blankets,journales,
and other helpful items)for the families.
Estimate$191.67 x 12 months=$2300
3004 Advertising 2,300 Advertising covers folders,flyers,envelopes and other materials to advertise to gather
volunteers and to inform first responders,other key stakeholders and the community
about the LOSS program. Also to cover registration fees for booths and events.
Estimate$191.67 x 12 months=$2300
3005 Staff Development&Training 4,000 Training will include trauma informed care interventions to include EMDR training and
consultation,and ongoing suicide loss and prevention education which may include
annual AAS and Loss Team Conferences.
3006 Staff Mileage 1,600 Mileage covers travel to and from scenes at Hind Hospice reimbursement rate of
.67/mile. Estimate for RFP is based on previous year total miles incurred.
199 miles x 12 months x.67=$1600
3007 Subscriptions&Memberships 323 Membership to professional organizations will be maintained to CAMTF(California
Association of Marriage and Family Theraists)and AAS(American Association of
Suicidology. These organizations are a source of information for internal use,other
resources for a community and for brochures. Senior Professional$209/year for AAS
and CAM FT dues are$114.
3009 Other(specify)-Retreat 19,500 The program brings LOSS clients together for a weekend of therapy and healing. The
cost is for two events per contract year and to include meals and lodging for
approximately 100 participants per year.
Cost for the retreat is$9,750 x 2 retreats=$19500
3010 Other(specify)-Background Checks 900 Background checks are conducted for each LOSS team member(staff and volunteers)
to ensure the safety and protection of the community. LOSS team members enter
homes and workplaces of survivors. Background checks can range in cost. We are
assuming the minium of$45 per basic check and this will cover 20 verifications per year.
3011 Other(specify)-Uniforms/Badges 500 All LOSS team members wear a designated uniform and carry identification when
providing professional on-scene support. Costs can vary and uniforms are for staff and
also for volunteers as a way to quickly identify our team on any scene or event.
3012 Other(specify)-Travel 1,000 Travel with Education;expenses related to travel to conference locations noted under
Education(Line#3005). Travel costs can vary with venue and time of year. This cost
could cover a round trip ticket and/or hotel expenses.
Exhibit E - Page 6 of 30
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000:DIRECT FACILITIES&EQUIPMENT 6,285
4002 Rent/Lease Building 4,125 Space is dedicated for counseling services,group therapy meetings,and administrative
sevices including the storage of literature. Based on Sq.Ft of Building and
measurement of office space and group session space. Lease provided as an additional
attachment.Approximately 275 sq.ft is dedicated to CG&H,specifically those spaces
with employees on the contract,and for group session space.275 sq ft x$15/sq ft=
4,125
4005 Security 2,160 Security;grief support groups are held in the evening to help ensure the safety of the
participants. Armed guard services include postings at entrances and escorts to cars
for clients;Rate is$30/hour for 1.6 hours for the 45 sessions held per year.
5000:DIRECT SPECIAL EXPENSES 1,300
5004 Translation Services 1,300 To meet the needs of our diverse community,we must provide means of effective
communication. This is a service is engaged on an as needed basis. Usage cannot be
predicted. However,when necessary,there will no delay in providing this to clients.
6000:INDIRECT EXPENSES 2,600
6003 Accounting/Bookkeeping 2,600 A.022 FTE is dedicatd to managing the contract,budget modifications and monthly
invoicing for the LOSS program.
Salary is$120K per year,120,000 x.022=2,600
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 257,891
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 257,891
BUDGET CHECK: -
Exhibit E - Page 7 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2025-2026
PROGRAM EXPENSES
1000:DIRECT SALARIES&BENEFITS
Direct Employee Salaries
Acct# Administrative Position FTE Admin Program Total
Direct Personnel Admin Salaries Subtotal 0.00 $ - $ -
Acct# Program Position FTE Admin Program Total
1116 Program Director 0.20 $ 28,840 $ 28,840
1117 Program Coordinator 0.80 $ 63,415 $ 63,415
1118 Licensed Clinician 0.20 $ 19,282 $ 19,282
1119 Bereavement Support Clinician 0.30 $ 19,282 $ 19,282
1120 After Hour On-Call Clinicians 2.70 $ 35,782 $ 35,782
1121 After Hour Response Clinicians 0.06 $ 8,652 $ 8,652
1122 Support Group Facilitation 0.04 $ 6,922 $ 6,922
Direct Personnel Program Salaries Subtotal 4.30 $ 182,175 $ 182,175
Admin Program Total
Direct Personnel Salaries Subtotal 4.30 $ - $ 182,175 $ 182,175
Direct Employee Benefits
Acct# Description Admin Program Total
1201 Retirement $ - $ 3,925 $ 3,925
1202 Worker's Compensation - $ 565 $ 565
1203 Health Insurance - $ 16,819 $ 16,819
1204 Other(specify)-Life Insurance - $ 278 $ 278
Direct Employee Benefits Subtotal: $ - $ 21,587 $ 21,587
Direct Payroll Taxes&Expenses:
Acct# Description Admin Program Total
1301 OASDI $ - $ - $ -
1302 FICA/MEDICARE - $ 13,938 $ 13,938
1303 SUI - $ 365 $ 365
Direct Payroll Taxes&Expenses Subtotal: $ - $ 14,303 $ 14,303
DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total
$ - $ 218,065 $ 218,065
DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program
0%1 1000
Exhibit E - Page 8 of 30
3000: DIRECT OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 2,472
3002 Printing/Postage $ 2,266
3003 Office, Household &Program Supplies $ 2,369
3004 Advertising $ 2,369
3005 Staff Development&Training $ 4,120
3006 Staff Mileage $ 1,648
3007 Subscriptions&Memberships $ 333
3009 Other(specify)-Retreat $ 20,085
3010 Other(specify)- Background Checks $ 927
3011 Other(specify)-Uniforms/Badges $ 515
3012 Other(specify)-Travel $ 1,030
DIRECT OPERATING EXPENSES TOTAL: $ 38,134
4000: DIRECT FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4002 Rent/Lease Building $ 4,125
4005 Security $ 2,182
DIRECT FACILITIES/EQUIPMENT TOTAL: $ 6,307
5000: DIRECT SPECIAL EXPENSES
Acct# I Line Item Description Amount
5004 ITranslation Services $ 1,339
DIRECT SPECIAL EXPENSES TOTAL: $ 1,339
6000: INDIRECT EXPENSES
Acct# Line Item Description Amount
Administrative Overhead
6001 Use this line and only this line for approved indirect cost rate $
Administrative Overhead
6003 Accounting/Bookkeeping $ 2,678
INDIRECT EXPENSES TOTAL $ 2,678
INDIRECT COST RATE 1.01%
TOTAL PROGRAM EXPENSES $ 2661523
PROGRAM FUNDING SOURCES
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8302 PEI- Prevention&Early Intervention Suicide Prevention $ 266,523
MHSA TOTAL $ 266,523
TOTAL PROGRAM FUNDING SOURCES: $ 266,523
NET PROGRAM COST: $ -
Exhibit E - Page 9 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2025-2026
PARTIAL FTE DETAIL
For all positions with FTE's split among multiple programs/contracts the below must be filled
out
Position Contract#/Name/Department/County FTE
Program Director Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Program Coordinator Fresno County LOSS Team 0.80
Other Programs 0.20
Total 1.00
Position Contract#/Name/Department/County FTE
Licensed Clinician Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Bereavement Support Clinician Fresno County LOSS Team 0.30
Other Programs 0.70
Total 1.00
Exhibit E - Page 10 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY)2025-2026 Budget Narrative
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:DIRECT SALARIES&BENEFITS 218,065
Administrative Positions -
Program Positions 182,175
1116 Program Director 28,840 The director is responsible for developing,coordinating,supervising,providing and/
assuring provision of bereavement services to through the Center for Grief and
Healing. Director oversees all aspects of the various bereavement programs and
provides supervision to staff involved in the Program. The Director also provides
direct services to LOSS clients.
0.2 FTE x 144,200 Annual Salary=28,840
1117 Program Coordinator 63,415 The Program Coordinator is responsible for coordinating and providing grief support
services,community education and outreach to include supervision of volunteers.
Program Coordinator also responds to LOSS calls that occur during normal business
hours.
0.8 FTE x 79,271 Annual Salary=63,415
1118 Licensed Clinician 19,282 The Licensed Clinician provides support to grieving individuals,couples and families.
Supports may include family counseling sessions and other supports.
0.2 FTE x 96,408 Annual Salary=19,282
1119 Bereavement Support Clinician 19,282 Bereavement Support Clinician will assist with data entry and reporting,bereavement
support phone calls,outreach and education,and administrative duties.
0.3 FTE x 64,272 Annual Salary=19,282
1120 After Hour On-Call Clinicians 35,782 On Call Clinicians take calls 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 responses to LOSS team requests. Clinicians are
required for immediate responses 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 volunteer and first responders. Rate is$6/hour for non holiday hours and
$9/hour for holidays.
350 days x 15 after hours x$6.18=32,445,plus holidays 15 days x 24 after hours x
$9.27=3,337,combined cost is$35,782
1121 After Hour Response Clinicians 8,652 The After Hours Response Clinician responds to LOSS calls outside of normal business
hours,providing immediate support and guidance to suicide LOSS survivors;also
conduct debriefing with the on scene volunteers. These are on site attendence. 48
calls @ an average of 2.5 hours/call at an overtime average rate of$72.10/hour=
$8,652
1122 Support Group Facilitation 6,922 Support groups are facilitated by a trained clinician and a total of 45 groups sessions
are held per year at an estimated average cost of$153.81/session. Group sessions are
conducted by a staff clinician. Groups are offered in evenings with overtime rates
applicable. These are conducted by Hinds employees on hourly salary rates;calcuated
at OT rate(two hours for group,group set up,group preparation at average rate of
$153.81 covering an average of 2 hours for each session;45 sessions x$153.81/
session=$6,720
Direct Employee Benefits 21,587
1201 Retirement 3,925 3%match up to 6%of allowable LOSS contract salary. Salaries for SOSL Program
Coord,Licensed Clinician,CGH Director,&Bereavement Clin Support(participants);
(63,415+19,282+28,840+19,282)x.06/2(to represent 3%match)
1202 Worker's Compensation 565 Starting with 2024 rates based on WC class codes and experience modifiers applied to
allowable LOSS contract salaries. WC rate for Class 8742 is.31%;Total salaries
182,175 x.31%=$565
1203 Health Insurance 16,819 Based on current negotiated rates;prorated over FTE($849.60/month/employee,4
employees with coverage,used FTE count or%of employee to prorate health care
insurance costs over Loss and Other. Participants are SOSL Program Coordinator at.8,
Licensed Clinical at.2,Program Director at.2,and Bereavement Clin Support at.3 FTE.
Then,the monthly cost is annualized by multiplying it by 12. (849.60 x.8)+(849.60 x
.2)+(849.46 x.2)+(849.46 x.3)and the total multiplied by 12=15,290;Health care
costs increases are estimated at 10%year;15,290 x 1.10=16,819
Exhibit E - Page 11 of 30
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1204 Other(specify)-Life Insurance 278 Benefit costs are based on federal/state mandated costs;benefits are based on best
market rates and negotiated each year,prorated per FTE. SOSL Coordinator is at 14.63
with.8=11.70,Licensed Clin is at 17.56 with.2 FTE=3.51, Program Director is at
26.79 at.2 FTE=5.36,,and the Bereavement Clin is at 8.74 with.3 FTE=2.62. The
Support Group Facilitator-no cost associated.Those rates(11.70+3.51+5.36+
2.62)x 12 months=278.35
Direct Payroll Taxes&Expenses: 14,303
1301 OASDI
1302 FICA/MEDICARE 13,938 17.65%x 182,175 LOSS contract salaries;IRS requirement for employer contribution
1303 SUI 365 .2%of LOSS contract allowable wages Of 182,175
3000:DIRECT OPERATING EXPENSES 38,134
3001 Telecommunications 2,472 Cell phones,dedicated LOSS landline,laptops and internet purchased and secured for
LOSS team usage. Estimate based on current run rates.
$51.5 x 4 staff x 12 months=$2472
3002 Printing/Postage 2,266 Postage will be used to mail out bereavement and informational resource packets to
families in our communities. Mailings include invitations to special events. Printing
costs cover flyers,brochures,informational packets and business cards. Estimated
average$188.83 x 12 months=$2266
3003 Office,Household&Program Supplies 2,369 The Program Supply,Office and Household budget will cover suicide grief goods for
children,resources from the American Foundation for Suicide Prevention(AFSP)and
Suicide Awareness Voices of Educatjion(SAVE),and kits containing blankets,journales,
and other helpful items)for the families.
Estimate$197.42 x 12 months=$2369
3004 Advertising 2,369 Advertising covers folders,flyers,envelopes and other materials to advertise to gather
volunteers and to inform first responders,other key stakeholders and the community
about the LOSS program. Also to cover registration fees for booths and events.
Estimate$197.42 x 12 months=$2369
3005 Staff Development&Training 4,120 Training will include trauma informed care interventions to include EMDR training and
consultation,and ongoing suicide loss and prevention education which may include
annual AAS and Loss Team Conferences.
3006 Staff Mileage 1,648 Mileage covers travel to and from scenes at Hind Hospice reimbursement rate of
.67/mile.
205 miles x 12 months x.67=$1648
3007 Subscriptions&Memberships 333 Membership to professional organizations will be maintained to CAMTF(California
Association of Marriage and FamilyTheraists)and AAS(American Association of
Suicidology. These organizations are a source of information for internal use,other
resources for a community and for brochures. Senior Professional$209/year for AAS
and CAMFT dues are$124.
3009 Other(specify)-Retreat 20,085 The program brings LOSS clients together for a weekend of therapy and healing.The
cost is for two events per contract year and to include meals and lodging for
approximately 100 participants per year.
Cost for the retreat is$10,042.5 x 2 retreats=$20085
3010 Other(specify)-Background Checks 927 Background checks are conducted for each LOSS team member(staff and volunteers)
to ensure the safety and protection of the community. LOSS team members enter
homes and workplaces of survivors. Background checks can range in cost. We are
assuming the minium of$46.35 per basic check and this will cover 20 verifications per
year.
3011 Other(specify)-Uniforms/Badges 515 All LOSS team members wear a designated uniform and carry identification when
providing professional on-scene support. Costs can vary and uniforms are for staff and
also for volunteers as a way to quickly identify our team on any scene or event.
3012 Other(specify)-Travel 1,030 Travel with Education;expenses related to travel to conference locations noted under
Education(Line#3005). Travel costs can vary with venue and time of year. This cost
could cover a round trip ticket and/or hotel expenses.
Exhibit E - Page 12 of 30
PROGRAM EXPENSE
ACCT#1 LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000:DIRECT FACILITIES&EQUIPMENT 6,307
4002 Rent/Lease Building 4,125 Space is dedicated for counseling services,group therapy meetings,and administrative
sevices including the storage of literature. Based on Sq.Ft of Building and
measurement of office space and group session space. Lease provided as an
additional attachment.Approximately 275 sq.ft is dedicated to CG&H,specifically
those spaces with employees on the contract,and for group session space.275 sq ft x
$15/sgft=4,125
4005 Security 2,182 Security;grief support groups are held in the evening to help ensure the safety of the
participants. Armed guard services include postings at entrances and escorts to cars
for clients;Rate is$30.31/hour for 1.6 hours for the 45 sessions held per year.
5000:DIRECT SPECIAL EXPENSES 1,339
5004 Translation Services 1,339 To meet the needs of our diverse community,we must provide means of effective
communication. This is a service is engaged on an as needed basis. Usage cannot be
predicted. However,when necessary,there will no delay in providing this to clients.
6000:INDIRECT EXPENSES 2,678
6003 Accounting/Bookkeeping 2,678 A.022 FTE is dedicatd to managing the contract,budget modifications and monthly
invoicing for the LOSS program.
Salary is 121,727 x.022=2,678
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 266,523
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 266,523
BUDGET CHECK: -
Exhibit E - Page 13 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2026-2027
PROGRAM EXPENSES
1000:DIRECT SALARIES&BENEFITS
Direct Employee Salaries
Acct# Administrative Position FTE Admin Program Total
Direct Personnel Admin Salaries Subtotal 0.00 $ - $ -
Acct# Program Position FTE Admin Program Total
1116 Program Director 0.20 $ 29,705 $ 29,705
1117 Program Coordinator 0.80 $ 65,318 $ 65,318
1118 Licensed Clinician 0.20 $ 19,860 $ 19,860
1119 Bereavement Support Clinician 0.30 $ 19,860 $ 19,860
1120 After Hour On-Call Clinicians 2.70 $ 36,856 $ 36,856
1121 After Hour Response Clinicians 0.06 $ 8,912 $ 8,912
1122 Support Group Facilitation 0.04 $ 7,129 $ 7,129
Direct Personnel Program Salaries Subtotal 4.30 $ 187,640 $ 187,640
Admin Program Total
Direct Personnel Salaries Subtotal 4.30 $ - $ 187,640 $ 187,640
Direct Employee Benefits
Acct# Description Admin Program Total
1201 Retirement $ $ 4,042 $ 4,042
1202 Worker's Compensation $ 582 $ 582
1203 Health Insurance $ 18,500 $ 18,500
1204 Other(specify)-Life Insurance $ 278 $ 278
Direct Employee Benefits Subtotal: $ - $ 23,402 $ 23,402
Direct Payroll Taxes&Expenses:
Acct# Description Admin Program Total
1301 OASDI $ $ - $ -
1302 FICA/MEDICARE $ 14,356 $ 14,356
1303 SUI $ 387 $ 387
Direct Payroll Taxes&Expenses Subtotal: $ - $ 14,743 $ 14,743
DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total
$ - $ 225,785 $ 225,785
DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program
0%1 100%
Exhibit E - Page 14 of 30
3000: DIRECT OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 2,546
3002 Printing/Postage $ 2,334
3003 Office, Household &Program Supplies $ 2,440
3004 Advertising $ 2,440
3005 Staff Development&Training $ 4,244
3006 Staff Mileage $ 1,697
3007 Subscriptions&Memberships $ 343
3009 Other(specify)-Retreat $ 20,688
3010 Other(specify)- Background Checks $ 955
3011 Other(specify)-Uniforms/Badges $ 530
3012 Other(specify)-Travel $ 1,061
DIRECT OPERATING EXPENSES TOTAL: $ 39,278
4000: DIRECT FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4002 Rent/Lease Building $ 4,125
4005 Security $ 2,247
DIRECT FACILITIES/EQUIPMENT TOTAL: $ 6,372
5000: DIRECT SPECIAL EXPENSES
Acct# I Line Item Description Amount
5004 ITranslation Services $ 1,379
DIRECT SPECIAL EXPENSES TOTAL: $ 1,379
6000: INDIRECT EXPENSES
Acct# Line Item Description Amount
Administrative Overhead
6001 Use this line and only this line for approved indirect cost rate $
Administrative Overhead
6003 Accounting/Bookkeeping $ 2,758
INDIRECT EXPENSES TOTAL $ 2,758
INDIRECT COST RATE 1.01%
TOTAL PROGRAM EXPENSES $ 2751572
PROGRAM FUNDING SOURCES
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8302 PEI- Prevention&Early Intervention Suicide Prevention $ 275,572
MHSA TOTAL $ 275,572
TOTAL PROGRAM FUNDING SOURCES: $ 275,572
NET PROGRAM COST: $ -
Exhibit E - Page 15 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2026-2027
PARTIAL FTE DETAIL
For all positions with FTE's split among multiple programs/contracts the below must be filled
out
Position Contract#/Name/Department/County FTE
Program Director Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Program Coordinator Fresno County LOSS Team 0.80
Other Programs 0.20
Total 1.00
Position Contract#/Name/Department/County FTE
Licensed Clinician Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Bereavement Support Clinician Fresno County LOSS Team 0.30
Other Programs 0.70
Total 1.00
Exhibit E - Page 16 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY)2026-2027 Budget Narrative
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:DIRECT SALARIES&BENEFITS 225,785
Administrative Positions -
Program Positions 187,640
1116 Program Director 29,705 The director is responsible for developing,coordinating,supervising,providing and/
assuring provision of bereavement services to through the Center for Grief and Healing.
Director oversees all aspects of the various bereavement programs and provides
supervision to staff involved in the Program. The Director also provides direct services
to LOSS clients.
0.2 FTE x 148,526 Annual Salary=29705
1117 Program Coordinator 65,318 The Program Coordinator is responsible for coordinating and providing grief support
services,community education and outreach to include supervision of volunteers.
Program Coordinator also responds to LOSS calls that occur during normal business
hours.
0.8 FTE x 81649 Annual Salary=66318
1118 Licensed Clinician 19,860 The Licensed Clinician provides support to grieving individuals,couples and families.
Supports may include family counseling sessions and other supports.
0.2 FTE x 99300 Annual Salary=19,860
1119 Bereavement Support Clinician 19,860 Bereavement Support Clinician will assist with data entry and reporting,bereavement
support phone calls,outreach and education,and administrative duties.
0.3 FTE x 66200 Annual Salary=19,860
1120 After Hour On-Call Clinicians 36,856 On Call Clinicians take calls 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 responses to LOSS team requests. Clinicians are required
for immediate responses 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 volunteer
and first responders. Rate is$6/hour for non holiday hours and$9/hour for holidays.
350 days x 15 after hours x$6.37=33443,plus holidays 15 days x 24 after hours x
$9.48=3,413,combined cost is$36856
1121 After Hour Response Clinicians 8,912 The After Hours Response Clinician responds to LOSS calls outside of normal business
hours,providing immediate support and guidance to suicide LOSS survivors;also
conduct debriefing with the on scene volunteers. These are on site attendence. 48
calls @ an average of 2.5 hours/call at an overtime average rate of$74.27/hour =
$8912
1122 Support Group Facilitation 7,129 Support groups are facilitated by a trained clinician and a total of 45 groups sessions
are held per year at an estimated average cost of$158.42/session. Group sessions are
conducted by a staff clinician. Groups are offered in evenings with overtime rates
applicable. These are conducted by Hinds employees on hourly salary rates;calcuated
at OT rate(two hours for group,group set up,group preparation at average rate of
$158.42 covering an average of 2 hours for each session;45 sessions x$158.42/
session=$7129
Direct Employee Benefits 23,402
1201 Retirement 4,042 3%match up to 6%of allowable LOSS contract salary. Salaries for SOSL Program Coord,
Licensed Clinician,CGH Director,&Bereavement Clin Support(participants);(65,318+
19,860+29,705+19,860)x.06/2(to represent 3%match)
1202 Worker's Compensation 582 Starting with 2024 rates based on WC class codes and experience modifiers applied to
allowable LOSS contract salaries. WC rate for Class 8742 is.31%;Total salaries
187,640 x.31%=$582
Exhibit E - Page 17 of 30
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1203 Health Insurance 18,500 Based on current negotiated rates;prorated over FTE($849.60/month/employee,4
employees with coverage,used FTE count or%of employee to prorate health care
insurance costs over Loss and Other. Participants are SOSL Program Coordinator at.8,
Licensed Clinical at.2,Program Director at.2,and Bereavement Clin Support at.3 FTE.
Then,the monthly cost is annualized by multiplying it by 12. (849.60 x.8)+(849.60 x
.2)+(849.46 x.2)+(849.46 x.3)and the total multiplied by 12=15,290;Health care
costs increases are estimated at 10%year;15,290 x 1.10=16,819;with add'I 10%
increase=18,501
1204 Other(specify)-Life Insurance 278 Benefit costs are based on federal/state mandated costs;benefits are based on best
market rates and negotiated each year,proratde per FTE. SOSL FTE is at 14.63 with.8=
11.70,Licensed Clin is at 17.56 with.2 FTE=3.51, Program Director is at 26.79 at.2
FTE=5.36,,and the Bereavement Clin is at 8.74 with.3 FTE=2.62. The Support Group
Facilitator-no cost associated.Those rates(11.70+3.51+5.36 +2.62)x 12 months=
278.35
Direct Payroll Taxes&Expenses: 14,743
1301 JOASDI
1302 FICA/MEDICARE 14,356 17.65%x 187,640 LOSS contract salaries;IRS requirement for employer contribution
1303 ISUI 387 .2%of LOSS contract allowable wages Of 187,640
3000:DIRECT OPERATING EXPENSES 39,278
3001 Telecommunications 2,546 Cell phones,dedicated LOSS landline,laptops and internet purchased and secured for
LOSS team usage. Estimate based on current run rates.
$53.04 x 4 staff x 12 months=$2546
3002 Printing/Postage 2,334 Postage will be used to mail out bereavement and informational resource packets to
families in our communities. Mailings include invitations to special events. Printing
costs cover flyers,brochures,informational packets and business cards. Estimated
average$194.5 x 12 months=$2334
3003 Office,Household&Program Supplies 2,440 The Program Supply,Office and Household budget will cover suicide grief goods for
children,resources from the American Foundation for Suicide Prevention(AFSP)and
Suicide Awareness Voices of Educatjion(SAVE),and kits containing blankets,journales,
and other helpful items)for the families.
Estimate$203.33 x 12 months=$2440
3004 Advertising 2,440 Advertising covers folders,flyers,envelopes and other materials to advertise to gather
volunteers and to inform first responders,other key stakeholders and the community
about the LOSS program. Also to cover registration fees for booths and events.
Estimate$203.33 x 12 months=$2440
3005 Staff Development&Training 4,244 Training will include trauma informed care interventions to include EMDR training and
consultation,and ongoing suicide loss and prevention education which may include
annual AAS and Loss Team Conferences.
3006 Staff Mileage 1,697 Mileage covers travel to and from scenes at Hind Hospice reimbursement rate of
.67/mile.
211 miles x 12 months x.67=$1697
3007 Subscriptions&Memberships 343 Membership to professional organizations will be maintained to CAMTF(California
Association of Marriage and Family Theraists)and AAS(American Association of
Suicidology. These organizations are a source of information for internal use,other
resources for a community and for brochures. Senior Professional$209/year for AAS
and CAM FT dues are$124.
3009 Other(specify)-Retreat 20,688 The program brings LOSS clients together for a weekend of therapy and healing. The
cost is for two events per contract year and to include meals and lodging for
approximately 100 participants per year.
Cost for the retreat is$10,334 x 2 retreats=$20688
3010 Other(specify)-Background Checks 955 Background checks are conducted for each LOSS team member(staff and volunteers)
to ensure the safety and protection of the community. LOSS team members enter
homes and workplaces of survivors. Background checks can range in cost. We are
assuming the minium of$47.75 per basic check and this will cover 20 verifications per
year.
3011 Other(specify)-Uniforms/Badges 530 All LOSS team members wear a designated uniform and carry identification when
providing professional on-scene support. Costs can vary and uniforms are for staff and
also for volunteers as a way to quickly identify our team on any scene or event.
3012 Other(specify)-Travel 1,061 Travel with Education;expenses related to travel to conference locations noted under
Education(Line#3005). Travel costs can vary with venue and time of year. This cost
could cover a round trip ticket and/or hotel expenses.
Exhibit E - Page 18 of 30
PROGRAM EXPENSE
ACCT#j LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000:DIRECT FACILITIES&EQUIPMENT 6,372
4002 Rent/Lease Building 4,125 Space is dedicated for counseling services,group therapy meetings,and administrative
sevices including the storage of literature. Based on Sq.Ft of Building and
measurement of office space and group session space. Lease provided as an additional
attachment.Approximately 275 sq.ft is dedicated to CG&H,specifically those spaces
with employees on the contract,and for group session space.275 sq ft x$15/sq ft=
4,125
4005 Security 2,247 Security;grief support groups are held in the evening to help ensure the safety of the
participants. Armed guard services include postings at entrances and escorts to cars
for clients;Rate is$31.21/hour for 1.6 hours for the 45 sessions held per year.
5000:DIRECT SPECIAL EXPENSES 1,379
5004 Translation Services 1,379 To meet the needs of our diverse community,we must provide means of effective
communication. This is a service is engaged on an as needed basis. Usage cannot be
predicted. However,when necessary,there will no delay in providing this to clients.
6000:INDIRECT EXPENSES 2,758
6003 Accounting/Bookkeeping 2,758 A.022 FTE is dedicatd to managing the contract,budget modifications and monthly
invoicing for the LOSS program.
Salary is 125,364 x.022=2,758
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 275,572
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 275,572 0
BUDGET CHECK: -
Exhibit E - Page 19 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2027-2028
PROGRAM EXPENSES
1000:DIRECT SALARIES&BENEFITS
Direct Employee Salaries
Acct# Administrative Position FTE Admin Program Total
Direct Personnel Admin Salaries Subtotal 0.00 $ - $ -
Acct# Program Position FTE Admin Program Total
1116 Program Director 0.20 $ 30,596 $ 30,596
1117 Program Coordinator 0.80 67,277 67,277
1118 Licensed Clinician 0.20 20,456 20,456
1119 Bereavement Support Clinician 0.30 20,456 20,456
1120 After Hour On-Call Clinicians 2.70 37,961 37,961
1121 After Hour Response Clinicians 0.06 9,179 9,179
1122 Support Group Facilitation 0.04 7,343 7,343
Direct Personnel Program Salaries Subtotal 4.30 $ 193,268 $ 193,268
Admin Program Total
Direct Personnel Salaries Subtotal 4.30 $ - $ 193,268 $ 193,268
Direct Employee Benefits
Acct# Description Admin Program Total
1201 Retirement $ $ 4,164 $ 4,164
1202 Worker's Compensation 600 600
1203 Health Insurance 20,351 20,351
1204 Other(specify)-Life Insurance 278 278
Direct Employee Benefits Subtotal: $ - $ 25,393 $ 25,393
Direct Payroll Taxes&Expenses:
Acct# Description Admin Program Total
1301 OASDI $ $ $ -
1302 FICA/MEDICARE 14,787 14,787
1303 SUI 387 387
Direct Payroll Taxes&Expenses Subtotal: $ - $ 15,174 $ 15,174
DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total
$ - $ 233,835 $ 233,835
DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program
0%1 100%
Exhibit E - Page 20 of 30
3000: DIRECT OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 2,623
3002 Printing/Postage 2,404
3003 Office, Household &Program Supplies 2,513
3004 Advertising 21513
3005 Staff Development&Training 4,371
3006 Staff Mileage 1,748
3007 Subscriptions&Memberships 353
3009 Other(specify)-Retreat 21,308
3010 Other(specify)- Background Checks 983
3011 Other(specify)-Uniforms/Badges 546
3012 Other(specify)-Travel 1,093
DIRECT OPERATING EXPENSES TOTAL: $ 40,456
4000: DIRECT FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4002 Rent/Lease Building 4,125
4005 Security 2,315
DIRECT FACILITIES/EQUIPMENT TOTAL: $ 6,440
5000: DIRECT SPECIAL EXPENSES
Acct# I Line Item Description Amount
5004 ITranslation Services 1,421
DIRECT SPECIAL EXPENSES TOTAL: $ 1,421
6000: INDIRECT EXPENSES
Acct# Line Item Description Amount
Administrative Overhead
6001 Use this line and only this line for approved indirect cost rate $
Administrative Overhead
6003 Accounting/Bookkeeping 2,841
INDIRECT EXPENSES TOTAL $ 2,841
INDIRECT COST RATE 1.01%
TOTAL PROGRAM EXPENSES $ 2841993
PROGRAM FUNDING SOURCES
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8302 PEI- Prevention&Early Intervention Suicide Prevention 284,993
MHSA TOTAL $ 284,993
TOTAL PROGRAM FUNDING SOURCES: $ 284,993
NET PROGRAM COST: $ -
Exhibit E - Page 21 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2027-2028
PARTIAL FTE DETAIL
For all positions with FTE's split among multiple programs/contracts the below must be filled
out
Position Contract#/Name/Department/County FTE
Program Director Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Program Coordinator Fresno County LOSS Team 0.80
Other Programs 0.20
Total 1.00
Position Contract#/Name/Department/County FTE
Licensed Clinician Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Bereavement Support Clinician Fresno County LOSS Team 0.30
Other Programs 0.70
Total 1.00
Exhibit E - Page 22 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY)2027-2028 Budget Narrative
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:DIRECT SALARIES&BENEFITS 233,835
Administrative Positions -
Program Positions 193,268
1116 Program Director 30,596 The director is responsible for developing,coordinating,supervising,providing and/
assuring provision of bereavement services to through the Center for Grief and
Healing. Director oversees all aspects of the various bereavement programs and
provides supervision to staff involved in the Program. The Director also provides
direct services to LOSS clients.
0.2 FTE x 152982 Annual Salary=30596
1117 Program Coordinator 67,277 The Program Coordinator is responsible for coordinating and providing grief support
services,community education and outreach to include supervision of volunteers.
Program Coordinator also responds to LOSS calls that occur during normal business
hours.
0.8 FTE x 84098 Annual Salary=67277
1118 Licensed Clinician 20,456 The Licensed Clinician provides support to grieving individuals,couples and families.
Supports may include family counseling sessions and other supports.
0.2 FTE x 102279 Annual Salary=20456
1119 Bereavement Support Clinician 20,456 Bereavement Support Clinician will assist with data entry and reporting,bereavement
support phone calls,outreach and education,and administrative duties.
0.3 FTE x 68186 Annual Salary=20456
1120 After Hour On-Call Clinicians 37,961 On Call Clinicians take calls 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 responses to LOSS team requests. Clinicians are
required for immediate responses 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 volunteer and first responders. Rate is$6/hour for non holiday hours and
$9/hour for holidays.
350 days x 15 after hours x$6.56=34440,plus holidays 15 days x 24 after hours x
$9.78=3,521,combined cost is$37961
1121 After Hour Response Clinicians 9,179 The After Hours Response Clinician responds to LOSS calls outside of normal business
hours,providing immediate support and guidance to suicide LOSS survivors;also
conduct debriefing with the on scene volunteers. These are on site attendence. 48
calls @ an average of 2.5 hours/call at an overtime average rate of$76.49/hour=
$8,652
1122 Support Group Facilitation 7,343 Support groups are facilitated by a trained clinician and a total of 45 groups sessions
are held per year at an estimated average cost of$163.18/session. Group sessions are
conducted by a staff clinician. Groups are offered in evenings with overtime rates
applicable. These are conducted by Hinds employees on hourly salary rates;calcuated
at OT rate(two hours for group,group set up,group preparation at average rate of
$163.18 covering an average of 2 hours for each session;45 sessions x$163.18/
session=$7343
Direct Employee Benefits 25,393
1201 Retirement 4,164 3%match up to 6%of allowable LOSS contract salary. Salaries for SOSL Program
Coord,Licensed Clinician,CGH Director,&Bereavement Clin Support(participants);
(67,277+30,596+ 20,456+,20,456)x.06/2(to represent 3%match)
1202 Worker's Compensation 600 Starting with 2024 rates based on WC class codes and experience modifiers applied to
allowable LOSS contract salaries. WC rate for Class 8742 is.31%;Total salaries
193,290.298,x.31%=$600
1203 Health Insurance 20,351 Based on current negotiated rates;prorated over FTE($849.60/month/employee,4
employees with coverage,used FTE count or%of employee to prorate health care
insurance costs over Loss and Other. Participants are SOSL Program Coordinator at.8,
Licensed Clinical at.2,Program Director at.2,and Bereavement Clin Support at.3 FTE.
Then,the monthly cost is annualized by multiplying it by 12. (849.60 x.8)+(849.60 x
.2)+(849.46 x.2)+(849.46 x.3)and the total multiplied by 12=15,290;Health care
costs increases are estimated at 10%year;15,290 x 1.10=16,819;with add'I 10%
increase=18,501;with 10%increase for year 18,501 x 1.10=20,351
Exhibit E - Page 23 of 30
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1204 Other(specify)-Life Insurance 278 Benefit costs are based on federal/state mandated costs;benefits are based on best
market rates and negotiated each year,proratde per FTE. SOSL FTE is at 14.63 with.8
=11.70,Licensed Clin is at 17.56 with.2 FTE=3.51, Program Director is at 26.79 at.2
FTE=5.36,,and the Bereavement Clin is at 8.74 with.3 FTE=2.62. The Support
Group Facilitator-no cost associated.Those rates(11.70+3.51+5.36+2.62)x 12
months=278.35
Direct Payroll Taxes&Expenses: 15,174
1301 OASDI -
1302 FICA/MEDICARE 14,787 7.65%x 193,290.29 LOSS contract salaries;IRS requirement for employer contribution
1303 SUI 387 1.2%of LOSS contract allowable wages Of 193,290.29
3000:DIRECT OPERATING EXPENSES 40,456
3001 Telecommunications 2,623 Cell phones,dedicated LOSS landline,laptops and internet purchased and secured for
LOSS team usage. Estimate based on current run rates.
$54.65 x 4 staff x 12 months=$2623
3002 Printing/Postage 2,404 Postage will be used to mail out bereavement and informational resource packets to
families in our communities. Mailings include invitations to special events. Printing
costs cover flyers,brochures,informational packets and business cards. Estimated
average$200.33 x 12 months=$2404
3003 Office,Household&Program Supplies 2,513 The Program Supply,Office and Household budget will cover suicide grief goods for
children,resources from the American Foundation for Suicide Prevention(AFSP)and
Suicide Awareness Voices of Educatjion(SAVE),and kits containing blankets,journales,
and other helpful items)for the families.
Estimate$209.42 x 12 months=$2513
3004 Advertising 2,513 Advertising covers folders,flyers,envelopes and other materials to advertise to gather
volunteers and to inform first responders,other key stakeholders and the community
about the LOSS program. Also to cover registration fees for booths and events.
Estimate$209.42 x 12 months=$2513
3005 Staff Development&Training 4,371 Training will include trauma informed care interventions to include EMDR training and
consultation,and ongoing suicide loss and prevention education which may include
annual AAS and Loss Team Conferences.
3006 Staff Mileage 1,748 Mileage covers travel to and from scenes at Hind Hospice reimbursement rate of
.67/mile.
217 miles x 12 months x.67=$1748
3007 Subscriptions&Memberships 353 Membership to professional organizations will be maintained to CAMTF(California
Association of Marriage and FamilyTheraists)and AAS(American Association of
Suicidology. These organizations are a source of information for internal use,other
resources for a community and for brochures. Senior Professional$209/year for AAS
and CAMFT dues are$124.
3009 Other(specify)-Retreat 21,308 The program brings LOSS clients together for a weekend of therapy and healing. The
cost is for two events per contract year and to include meals and lodging for
approximately 100 participants per year.
Cost for the retreat is$10,654 x 2 retreats=$21308
3010 Other(specify)-Background Checks 983 Background checks are conducted for each LOSS team member(staff and volunteers)
to ensure the safety and protection of the community. LOSS team members enter
homes and workplaces of survivors. Background checks can range in cost. We are
assuming the minium of$49.15 per basic check and this will cover 20 verifications per
year.
3011 Other(specify)-Uniforms/Badges S46 All LOSS team members wear a designated uniform and carry identification when
providing professional on-scene support. Costs can vary and uniforms are for staff and
also for volunteers as a way to quickly identify our team on any scene or event.
3012 Other(specify)-Travel 1,093 Travel with Education;expenses related to travel to conference locations noted under
Education(Line#3005). Travel costs can vary with venue and time of year. This cost
could cover a round trip ticket and/or hotel expenses.
Exhibit E - Page 24 of 30
PROGRAM EXPENSE
ACCT#1 LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000:DIRECT FACILITIES&EQUIPMENT 6,440
4002 Rent/Lease Building 4,125 Space is dedicated for counseling services,group therapy meetings,and administrative
sevices including the storage of literature. Based on Sq.Ft of Building and
measurement of office space and group session space. Lease provided as an
additional attachment.Approximately 275 sq.ft is dedicated to CG&H,specifically
those spaces with employees on the contract,and for group session space.275 sq ft x
$15/sgft=4,125
4005 Security 2,315 Security;grief support groups are held in the evening to help ensure the safety of the
participants. Armed guard services include postings at entrances and escorts to cars
for clients;Rate is$32.15/hour for 1.6 hours for the 45 sessions held per year.
5000:DIRECT SPECIAL EXPENSES 1,421
5004 Translation Services 1,421 To meet the needs of our diverse community,we must provide means of effective
communication. This is a service is engaged on an as needed basis. Usage cannot be
predicted. However,when necessary,there will no delay in providing this to clients.
6000:INDIRECT EXPENSES 2,841
6003 Accounting/Bookkeeping 2,841 A.022 FTE is dedicatd to managing the contract,budget modifications and monthly
invoicing for the LOSS program.
Salary is 129136 x.022=2841
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 284,993
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 284,993
BUDGET CHECK: -
Exhibit E - Page 25 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2028-2029
PROGRAM EXPENSES
1000:DIRECT SALARIES&BENEFITS
Direct Employee Salaries
Acct# Administrative Position FTE Admin Program Total
Direct Personnel Admin Salaries Subtotal 0.00 $ - $ -
Acct# Program Position FTE Admin Program Total
1116 Program Director 0.20 $ 31,514 $ 31,514
1117 Program Coordinator 0.80 $ 69,295 $ 69,295
1118 Licensed Clinician 0.20 $ 21,070 $ 21,070
1119 Bereavement Support Clinician 0.30 $ 21,070 $ 21,070
1120 After Hour On-Call Clinicians 2.70 $ 39,100 $ 39,100
1121 After Hour Response Clinicians 0.06 $ 9,455 $ 9,455
1122 Support Group Facilitation 0.04 $ 7,563 $ 7,563
Direct Personnel Program Salaries Subtotal 4.30 $ 199,067 $ 199,067
Admin Program Total
Direct Personnel Salaries Subtotal 4.30 $ - $ 199,067 $ 199,067
Direct Employee Benefits
Acct# Description Admin Program Total
1201 Retirement $ $ 4,289 $ 4,289
1202 Worker's Compensation $ 617 $ 617
1203 Health Insurance $ 20,967 $ 20,967
1204 Other(specify)-Life Insurance $ 278 $ 278
Direct Employee Benefits Subtotal: $ - $ 26,151 $ 26,151
Direct Payroll Taxes&Expenses:
Acct# Description Admin Program Total
1301 OASDI $ $ $ -
1302 FICA/MEDICARE $ 15,230 $ 15,230
1303 SUI $ 398 $ 398
Direct Payroll Taxes&Expenses Subtotal: $ - $ 15,628 $ 15,628
DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total
$ - $ 240,846 $ 240,846
DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program
0%1 100%
Exhibit E - Page 26 of 30
3000: DIRECT OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 2,701
3002 Printing/Postage $ 2,476
3003 Office, Household &Program Supplies $ 2,589
3004 Advertising $ 2,589
3005 Staff Development&Training $ 4,502
3006 Staff Mileage $ 1,801
3007 Subscriptions&Memberships $ 364
3009 Other(specify)-Retreat $ 21,947
3010 Other(specify)- Background Checks $ 1,013
3011 Other(specify)-Uniforms/Badges $ 563
3012 Other(specify)-Travel $ 1,126
DIRECT OPERATING EXPENSES TOTAL: $ 41,670
4000: DIRECT FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4002 Rent/Lease Building $ 4,125
4005 Security $ 2,384
DIRECT FACILITIES/EQUIPMENT TOTAL: $ 6,509
5000: DIRECT SPECIAL EXPENSES
Acct# I Line Item Description Amount
5004 ITranslation Services $ 1,463
DIRECT SPECIAL EXPENSES TOTAL: $ 1,463
6000: INDIRECT EXPENSES
Acct# Line Item Description Amount
Administrative Overhead
6001 Use this line and only this line for approved indirect cost rate $
Administrative Overhead
6003 Accounting/Bookkeeping $ 2,926
INDIRECT EXPENSES TOTAL $ 2,926
INDIRECT COST RATE 1.01%
TOTAL PROGRAM EXPENSES $ 2931414
PROGRAM FUNDING SOURCES
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8302 PEI- Prevention&Early Intervention Suicide Prevention $ 293,414
MHSA TOTAL $ 293,414
TOTAL PROGRAM FUNDING SOURCES: $ 293,414
NET PROGRAM COST: $ -
Exhibit E - Page 27 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS (LOSS)TEAM
Hinds Hospice
Fiscal Year(FY) 2028-2029
PARTIAL FTE DETAIL
For all positions with FTE's split among multiple programs/contracts the below must be filled
out
Position Contract#/Name/Department/County FTE
Program Director Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Program Coordinator Fresno County LOSS Team 0.80
Other Programs 0.20
Total 1.00
Position Contract#/Name/Department/County FTE
Licensed Clinician Fresno County LOSS Team 0.20
Other Programs 0.80
Total 1.00
Position Contract#/Name/Department/County FTE
Bereavement Support Clinician Fresno County LOSS Team 0.30
Other Programs 0.70
Total 1.00
Exhibit E - Page 28 of 30
LOCAL OUTREACH TO SUICIDE SURVIVORS(LOSS)TEAM
Hinds Hospice
Fiscal Year(FY)2028-2029 Budget Narrative
PROGRAM EXPENSE
ACCT#I LINE ITEM ANT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:DIRECT SALARIES&BENEFITS 240,846
Administrative Positions -
Program Positions 199,067
1116 Program Director 31,514 The director is responsible for developing,coordinating,supervising,providing and/
assuring provision of bereavement services to through the Center for Grief and
Healing. Director oversees all aspects of the various bereavement programs and
provides supervision to staff involved in the Program. The Director also provides
direct services to LOSS clients.
0.2 FTE x 157571 Annual Salary=31514
1117 Program Coordinator 69,295 The Program Coordinator is responsible for coordinating and providing grief support
services,community education and outreach to include supervision of volunteers.
Program Coordinator also responds to LOSS calls that occur during normal business
hours.
0.8 FTE x 86621 Annual Salary=69295
1118 Licensed Clinician 21,070 The Licensed Clinician provides support to grieving individuals,couples and families.
Supports may include family counseling sessions and other supports.
0.2 FTE x 105348 Annual Salary=21070
1119 Bereavement Support Clinician 21,070 Bereavement Support Clinician will assist with data entry and reporting,bereavement
support phone calls,outreach and education,and administrative duties.
0.3 FTE x 70232 Annual Salary=21720
1120 After Hour On-Call Clinicians 39,100 On Call Clinicians take calls 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 responses to LOSS team requests. Clinicians are
required for immediate responses 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 volunteer and first responders. Rate is$6/hour for non holiday hours and
$9/hour for holidays.
350 days x 15 after hours x$6.75=35438,plus holidays 15 days x 24 after hours x
$10.17=3662,combined cost is$39100
1121 After Hour Response Clinicians 9,455 The After Hours Response Clinician responds to LOSS calls outside of normal business
hours,providing immediate support and guidance to suicide LOSS survivors;also
conduct debriefing with the on scene volunteers.These are on site attendence. 48
calls @ an average of 2.5 hours/call at an overtime average rate of$84.04/hour=
$9455
1122 Support Group Facilitation 7,563 Support groups are facilitated by a trained clinician and a total of 45 groups sessions
are held per year at an estimated average cost of$168.07/session. Group sessions are
conducted by a staff clinician. Groups are offered in evenings with overtime rates
applicable. These are conducted by Hinds employees on hourly salary rates;calcuated
at OT rate(two hours for group,group set up,group preparation at average rate of
$168.07 covering an average of 2 hours for each session;45 sessions x$168.07/
session=$7563
Direct Employee Benefits 26,151
1201 Retirement 4,289 3%match up to 6%of allowable LOSS contract salary. Salaries for SOSL Program
Coord,Licensed Clinician,CGH Director,&Bereavement Clin Support(participants);
(69,295+31,514+ 21,070+21,070)x.06/2(to represent 3%match)
1202 Worker's Compensation 617 Starting with 2024 rates based on WC class codes and experience modifiers applied to
allowable LOSS contract salaries. WC rate for Class 8742 is.31%;Total salaries
199,067 x.31%=$617
1203 Health Insurance 20,967 Based on current negotiated rates;prorated over FTE($849.60/month/employee,4
employees with coverage,used FTE count or%of employee to prorate health care
insurance costs over Loss and Other. Participants are SOSL Program Coordinator at.8,
Licensed Clinical at.2,Program Director at.2,and Bereavement Clin Support at.3 FTE.
Then,the monthly cost is annualized by multiplying it by 12. (849.60 x.8)+(849.60 x
.2)+(849.46 x.2)+(849.46 x.3)and the total multiplied by 12=15,290;Health care
costs increases are estimated at 10%year;15,290 x 1.10=16,819;with add'I 10%
increase=18,501;with 10%increase for year 18,501 x 1.10=20,351,and the last year
with a 10%increase in healthcare costs,20,351 x 1.10=20,967
Exhibit E - Page 29 of 30
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1204 Other(specify)-Life Insurance 278 Benefit costs are based on federal/state mandated costs;benefits are based on best
market rates and negotiated each year,proratde per FTE. SOSL FTE is at 14.63 with.8
=11.70,Licensed Clin is at 17.56 with.2 FTE=3.51, Program Director is at 26.79 at.2
FTE=5.36,,and the Bereavement Clin is at 8.74 with.3 FTE=2.62. The Support
Group Facilitator-no cost associated.Those rates(11.70+3.51+5.36+2.62)x 12
months=278.35
Direct Payroll Taxes&Expenses: 15,628
1301 OASDI -
1302 FICA/MEDICARE 15,230 7.65%x 199,067.00 LOSS contract salaries;IRS requirement for employer contribution
1303 SUI 398 1.2%of LOSS contract allowable wages Of 199,067.00
3000:DIRECT OPERATING EXPENSES 41,670
3001 Telecommunications 2,701 Cell phones,dedicated LOSS landline,laptops and internet purchased and secured for
LOSS team usage. Estimate based on current run rates.
$56.27 x 4 staff x 12 months=$2623
3002 Printing/Postage 2,476 Postage will be used to mail out bereavement and informational resource packets to
families in our communities. Mailings include invitations to special events. Printing
costs cover flyers,brochures,informational packets and business cards. Estimated
average$206.33 x 12 months=$2476
3003 Office,Household&Program Supplies 2,589 The Program Supply,Office and Household budget will cover suicide grief goods for
children,resources from the American Foundation for Suicide Prevention(AFSP)and
Suicide Awareness Voices of Educatjion(SAVE),and kits containing blankets,journales,
and other helpful items)for the families.
Estimate$215.75 x 12 months=$2589
3004 Advertising 2,589 Advertising covers folders,flyers,envelopes and other materials to advertise to gather
volunteers and to inform first responders,other key stakeholders and the community
about the LOSS program. Also to cover registration fees for booths and events.
Estimate$215.75 x 12 months=$2589
3005 Staff Development&Training 4,502 Training will include trauma informed care interventions to include EMDR training and
consultation,and ongoing suicide loss and prevention education which may include
annual AAS and Loss Team Conferences.
3006 Staff Mileage 1,801 Mileage covers travel to and from scenes at Hind Hospice reimbursement rate of
.67/mile.
224 miles x 12 months x.67=$1801
3007 Subscriptions&Memberships 364 Membership to professional organizations will be maintained to CAMTF(California
Association of Marriage and FamilyTheraists)and AAS(American Association of
Suicidology. These organizations are a source of information for internal use,other
resources for a community and for brochures. Senior Professional$209/year for AAS
and CAMFT dues are$155.
3009 Other(specify)-Retreat 21,947 The program brings LOSS clients together for a weekend of therapy and healing. The
cost is for two events per contract year and to include meals and lodging for
approximately 100 participants per year.
Cost for the retreat is$10,973.5 x 2 retreats=$21947
3010 Other(specify)-Background Checks 1,013 Background checks are conducted for each LOSS team member(staff and volunteers)
to ensure the safety and protection of the community. LOSS team members enter
homes and workplaces of survivors. Background checks can range in cost. We are
assuming the minium of$50.65 per basic check and this will cover 20 verifications per
year.
3011 Other(specify)-Uniforms/Badges 563 All LOSS team members wear a designated uniform and carry identification when
providing professional on-scene support. Costs can vary and uniforms are for staff and
also for volunteers as a way to quickly identify our team on any scene or event.
3012 Other(specify)-Travel 1,126 Travel with Education;expenses related to travel to conference locations noted under
Education(Line#3005). Travel costs can vary with venue and time of year. This cost
could cover a round trip ticket and/or hotel expenses.
Exhibit E - Page 30 of 30
PROGRAM EXPENSE
ACCT#1 LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
4000:DIRECT FACILITIES&EQUIPMENT 6,509
4002 Rent/Lease Building 4,125 Space is dedicated for counseling services,group therapy meetings,and administrative
sevices including the storage of literature. Based on Sq.Ft of Building and
measurement of office space and group session space. Lease provided as an
additional attachment.Approximately 275 sq.ft is dedicated to CG&H,specifically
those spaces with employees on the contract,and for group session space.275 sq ft x
$15/sgft=4,125
4005 Security 2,384 Security;grief support groups are held in the evening to help ensure the safety of the
participants. Armed guard services include postings at entrances and escorts to cars
for clients;Rate is$33.11/hour for 1.6 hours for the 45 sessions held per year.
5000:DIRECT SPECIAL EXPENSES 1,463
5004 Translation Services 1,463 To meet the needs of our diverse community,we must provide means of effective
communication. This is a service is engaged on an as needed basis. Usage cannot be
predicted. However,when necessary,there will no delay in providing this to clients.
6000:INDIRECT EXPENSES 2,926
6003 Accounting/Bookkeeping 2,926 A.022 FTE is dedicatd to managing the contract,budget modifications and monthly
invoicing for the LOSS program.
Salary is 133000 x.022=2926
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 293,414
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 293,414
BUDGET CHECK: -
Exhibit F - Page 1 of 4
Insurance Requirements
1. Required Policies
Without limiting the County's right to obtain indemnification from the 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 Two Million Dollars ($2,000,000) per occurrence and an annual aggregate of
Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis.
Coverage must include products, completed operations, property damage, bodily injury,
personal injury, and advertising injury. The Contractor shall obtain an endorsement to
this policy naming the County of Fresno, its officers, agents, employees, and volunteers,
individually and collectively, as additional insureds, but only insofar as the operations
under this Agreement are concerned. Such coverage for additional insureds will apply as
primary insurance and any other insurance, or self-insurance, maintained by the County
is excess only and not contributing with insurance provided under the Contractor's
policy.
(B) Automobile Liability. Automobile liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence for bodily injury and for property damages.
Coverage must include any auto used in connection with this Agreement.
(C)Workers Compensation. Workers compensation insurance as required by the laws of
the State of California with statutory limits.
(D) Employer's Liability. Employer's liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence for bodily injury and for disease.
(E) Professional Liability. Professional 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). If this is a claims-made policy, then (1)the retroactive date must
be prior to the date on which services began under this Agreement; (2)the Contractor
shall maintain the policy and provide to the County annual evidence of insurance for not
less than five years after completion of services under this Agreement; and (3) if the
policy is canceled or not renewed, and not replaced with another claims-made policy
with a retroactive date prior to the date on which services begin under this Agreement,
then the Contractor shall purchase extended reporting coverage on its claims-made
policy for a minimum of five years after completion of services under this Agreement.
(F) Molestation Liability. Sexual abuse/ molestation liability insurance with limits of not
less than Two Million Dollars ($2,000,000) per occurrence, with an annual aggregate of
Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis.
(G)Cyber Liability. Cyber liability insurance with limits of not less than Two Million Dollars
($2,000,000) per occurrence. Coverage must include claims involving Cyber Risks. The
cyber liability policy must be endorsed to cover the full replacement value of damage to,
alteration of, loss of, or destruction of intangible property (including but not limited to
information or data) that is in the care, custody, or control of the Contractor.
Exhibit F - Page 2 of 4
Definition of Cyber Risks. "Cyber Risks" include but are not limited to (i) Security
Breach, which may include Disclosure of Personal Information to an Unauthorized Third
Party; (ii) data breach; (iii) breach of any of the Contractor's obligations under [identify
the Article, section, or exhibit containing data security obligations] of this Agreement; (iv)
system failure; (v) data recovery; (vi) failure to timely disclose data breach or Security
Breach; (vii) failure to comply with privacy policy; (viii) payment card liabilities and costs;
(ix) infringement of intellectual property, including but not limited to infringement of
copyright, trademark, and trade dress; (x) invasion of privacy, including release of
private information; (xi) information theft; (xii) damage to or destruction or alteration of
electronic information; (xiii) cyber extortion; (xiv) extortion related to the Contractor's
obligations under this Agreement regarding electronic information, including Personal
Information; (xv)fraudulent instruction; (xvi) funds transfer fraud; (xvii) telephone fraud;
(xviii) network security; (xix) data breach response costs, including Security Breach
response costs; (xx) regulatory fines and penalties related to the Contractor's obligations
under this Agreement regarding electronic information, including Personal Information;
and (xxi) credit monitoring expenses.
2. Additional Requirements
(A) Verification of Coverage. Within 30 days after the Contractor signs this Agreement,
and at any time during the term of this Agreement as requested by the County's Risk
Manager or the County Administrative Office, the Contractor shall deliver, or cause its
broker or producer to deliver, to the County Risk Manager, at 2220 Tulare Street, 16th
Floor, Fresno, California 93721, or HRRiskManagement@fresnocountyca.gov, and by
mail or email to the person identified to receive notices under this Agreement,
certificates of insurance and endorsements for all of the coverages required under this
Agreement.
(i) Each insurance certificate must state that: (1) the insurance coverage has been
obtained and is in full force; (2) the County, its officers, agents, employees, and
volunteers are not responsible for any premiums on the policy; and (3) the
Contractor has waived its right to recover from the County, its officers, agents,
employees, and volunteers any amounts paid under any insurance policy
required by this Agreement and that waiver does not invalidate the insurance
policy.
(ii) The commercial general liability insurance certificate must also state, and include
an endorsement, that the County of Fresno, its officers, agents, employees, and
volunteers, individually and collectively, are additional insureds insofar as the
operations under this Agreement are concerned. The commercial general liability
insurance certificate must also state that the coverage shall apply as primary
insurance and any other insurance, or self-insurance, maintained by the County
shall be excess only and not contributing with insurance provided under the
Contractor's policy.
(iii) The automobile liability insurance certificate must state that the policy covers any
auto used in connection with this Agreement.
Exhibit F - Page 3 of 4
(iv) The professional liability insurance certificate, if it is a claims-made policy, must
also state the retroactive date of the policy, which must be prior to the date on
which services began under this Agreement.
(v) The cyber liability insurance certificate must also state that it is endorsed, and
include an endorsement, to cover the full replacement value of damage to,
alteration of, loss of, or destruction of intangible property (including but not limited
to information or data) that is in the care, custody, or control of the Contractor.
(B) Acceptability of Insurers. All insurance policies required under this Agreement must be
issued by admitted insurers licensed to do business in the State of California and
possessing at all times during the term of this Agreement an A.M. Best, Inc. rating of no
less than A: VI I.
(C) Notice of Cancellation or Change. For each insurance policy required under this
Agreement, the Contractor shall provide to the County, or ensure that the policy requires
the insurer to provide to the County, written notice of any cancellation or change in the
policy as required in this paragraph. For cancellation of the policy for nonpayment of
premium, the Contractor shall, or shall cause the insurer to, provide written notice to the
County not less than 10 days in advance of cancellation. For cancellation of the policy
for any other reason, and for any other change to the policy, the Contractor shall, or shall
cause the insurer to, provide written notice to the County not less than 30 days in
advance of cancellation or change. The County in its sole discretion may determine that
the failure of the Contractor or its insurer to timely provide a written notice required by
this paragraph is a breach of this Agreement.
(D) County's Entitlement to Greater Coverage. If the Contractor has or obtains insurance
with broader coverage, higher limits, or both, than what is required under this
Agreement, then the County requires and is entitled to the broader coverage, higher
limits, or both. To that end, the Contractor shall deliver, or cause its broker or producer
to deliver, to the County's Risk Manager certificates of insurance and endorsements for
all of the coverages that have such broader coverage, higher limits, or both, as required
under this Agreement.
(E) Waiver of Subrogation. The Contractor waives any right to recover from the County, its
officers, agents, employees, and volunteers any amounts paid under the policy of
worker's compensation insurance required by this Agreement. The Contractor is solely
responsible to obtain any policy endorsement that may be necessary to accomplish that
waiver, but the Contractor's waiver of subrogation under this paragraph is effective
whether or not the Contractor obtains such an endorsement.
(F) County's Remedy for Contractor's Failure to Maintain. If the Contractor fails to keep
in effect at all times any insurance coverage required under this Agreement, the County
may, in addition to any other remedies it may have, suspend or terminate this
Agreement upon the occurrence of that failure, or purchase such insurance coverage,
and charge the cost of that coverage to the Contractor. The County may offset such
charges against any amounts owed by the County to the Contractor under this
Agreement.
Exhibit F - Page 4 of 4
(G)Subcontractors. The Contractor shall require and verify that all subcontractors used by
the Contractor to provide services under this Agreement maintain insurance meeting all
insurance requirements provided in this Agreement. This paragraph does not authorize
the Contractor to provide services under this Agreement using subcontractors.
Exhibit G - Page 1 of 1
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
the individuals served 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 H - Page 1 of 10
INCIDENT REPORTING
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
The Incident Report must be completed for all incidents involving individuals served through
DBH's current incident reporting portal, Logic Manager, at
https:Hfresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182beOc5cdcd5072bb1864cdee
4d3d6e
• The reporting portal is available 24 hours a day, every day.
• Any employee of the Contractor can submit an incident using the reporting portal at
any time. No login is required.
• The designated administrator of the Contractor can add information to the follow up
section of the report after submission.
• When an employee submits an incident within 24 hours from the time of the incident
or first knowledge of the incident, the Contractor's designated administrator, the
assigned contract analyst and the Incident Reporting email inbox will be notified
immediately via email from the Logic Manager system that there is a new incident to
review.
• Meeting the 24 hour incident reporting requirements will be easier as there are no
signatures to collect.
• The user guide attached identifies the reporting process and the reviewer process,
and is subject to updates based on DBH's selected incident reporting portal system.
• Employees involved in a crisis incident should be offered appropriate Employee
Assistance Program (EAP) or similar related wellness and recovery assistance. In
conjunction with the DBH's Guiding Principles of Care Delivery and wellness of the
workforce, Contractor shall align their practices around this vision and ensure
needed debriefing services are offered to all employees involved in a crisis incident.
Employees shall be afforded all services to strengthen their recovery and wellness
related to the crisis incident. Appropriate follow-up with the employee shall be carried
out and a plan for workforce wellness shall be submitted to DBH.
Questions about incident reporting, how to use the incident reporting portal, or
designating/changing the name of the administrator who will review incidents for the Contractor
should be emailed to DBHlncidentReporting@fresnocountyca.gov and the assigned contract
analyst.
Exhibit H - Page 2 of 10
cot, Mental Health Plan (MHP) and Substance Use Disorder(SUD) services
1 Incident Reporting System
°ems ° INCIDENT REVIEWER ROLE — User Guide
Fresno County Department of Behavioral Health (DBH) requires all of its county-operated and contracted
providers (through the Mental Health Plan (MHP) and Substance Use Disorder (SUD) services) to complete
a written report of any incidents compromising the health and safety of persons served, employees, or
community members.
Yes! Incident reports will now be made through an on online reporting portal hosted by Logic Manager. It's
an easier way for any employee to report an incident at any time. A few highlights:
• No supervisor signature is immediately required.
• Additional information can be added to the report by the program supervisor/manager without
having to resubmit the incident.
• When an incident is submitted, the assigned contract analyst, program supervisor/manager,
clinical supervisor and the DBHlncidentReporting mailbox automatically receives an email
notification of a new incident and can log in any time to review the incident. Everything that
was on the original paper/electronic form matches the online form.
• Do away with submitting a paper version with a signature.
• This online submission allows for timely action for the health and safety of the persons-served,
as well as compliance with state reporting timelines when necessary.
As an Incident Reviewer, the responsibility is to:
• Log in to Logic Manager and review incident submitted within 48 hours of notification of incident.
• Review incident for clarity, missing information and add in additional information deemed
appropriate.
• Notify DBHlncidentReporting@fresnocountyca.gov if there is additional information to be report
after initial submission
• Contact.DBHlncidentReporting@fresnocountVca.gov if there are any concerns, questions or
comments with Logic Manager or incident reporting.
Below is the link to report incidents
https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcd5072bbl864cdee4d3d6e
The link will take employees to the reporting screen to begin incident submission:
Exhibit H - Page 3 of 10
F C {] 6 fmsnodbh.logicmanageccom/incidents/?t=9&p=1&k=182beOc5cdcd5O72bb1864cdee4d3d6e
'Logic
Incident Report
Please complete this form
' Client Information
Name of Facility'
Name of Reporting Party'
Facility Address'
Facility Phone Number'
Mental Health or Substance Use Disorder Program?'
sdcctodor
Client First Name'
Client Last Name'
i
Client Date of Birth
-/-/yryy
Client Address
i
Client ID
Gender'
County of Origin'
Summary
Subject O
Incident(check all that apply)'
select optonlsi
If Other-specify(i.e.fire,poisoning,epidemic outbreaks,other catastrophes/events that jeopardize the welfare and safety of clients,staff and/or members of the community):
Entertert
Description of the incident'
Enter taut
Exhibit H - Page 4 of 10
Similar to the paper version, multiple incident categories can be selected
Incident(check all that apply)`
Medical Emergency x Death of Client -
Homicide/Homicide Attempt
AWOL/Elopement from locked facility
Vlolence/Abuse/Assault(toward others,client and/or property
Attempted Suicide(resulting in serious injury)
Injury(self-inflicted or by accident)
Medication Error
F C Q O fresnodbh.logicmaoeger.com/incidents/?t=9&p=l&k=182be0cScdcdSG72bbl864cdee4d3d6e
Date of Incident'
Time of Incident'
Enter tex.
Location of Incident*
Key People Directly Involved in Incident(witnesses,staff)'
Did the Injured Party seek Medical Attention?
Attach any additional details
B Add File or Drop File Here
Reported By Name'
Entcrtcx_
Reported By Email'
Reported On
10/30/2019
Exhibit H - Page 5 of 10
As another bonus feature, either drag files(such as a copy of a IJOR, additional statements/document) or click on
Add File to upl ad a file.
E C fl i fresnodbh.logicmanagecco me sRt=9&0=1&k=182be0c5cdcd5072bb1864cdee4d3d6e
B Add File or Drop File Here
Reported By Name'
Reported By Email'
cntnr tcn
Reported On
10/30/2019
Follow Up
Action Taken(check all that apply)-
Please specify if other
Description of Action Taken'
LnM te:a
Outcome'
Similar to the paper version, multiple Action Taken categories can be selected.
Follow Up
Action Taken(check all that apply)
Law Enforcement Contacted x Called 911/EMS x -
Consulted with Physician
First Ald/CPR Administered
Client removed from building
Parent/Legal Guardian Contacted
Other
When done entering all the information,simply click submit.
Any fields that have a red asterisk, require information an will prevent submission of the form if left blank.
Exhibit H - Page 6 of 10
A"Thank you for your submission"statement will pop up if an incident is successfully submitted. Click"Reload the
Form"to submit another incident.
LogicManager
Thank you for your submission[
RELOAD THE FORM
A Notification email will be received when a new incident is reported, or a new comment has been made regarding
an incident. Click on "Open this incident in Logic Manager" and the Logic Manager login screen will show.
Wed 10/30/2019 10:40 AM
SL SYSTEM LogicManager via custom r.support@logicmanager.com <customer.support@ log icmanager.com>
tJ Notification-
To DBH Incident Reporting
0 K there are problems with how this message is displayed,click here to view it in a web o
Click here to download pictures.To help protect your privacy,outlook prevented autom c download of some pictures in this message.
CAUTION H-EXTERNAL EMAIL-THINK BEFORE YOU CLICK
U RgFecihaRP rb Mdllw�bdwnbd pimr T bpubapur
Prmry•OuLLi1 PrewMed aMelk bnkW dtliwR Pdrie Ran Fe
Infant.
1ng41anegv,rM.
Hi Mila Arevalo,
You have received a notification through LogicManager_Please see the details
below.
Type:Incident Report
Subject:102:
Notifiratlon To:Mila Arevalo
Open this incident in LogicManager
If using Internet Explorer,dick here to open the notification.
This email was generated by LogicManager.If you have any technical issues,
please email sucoorticb1ceicmanacter.com.
Exhibit H - Page 7 of 10
Enter in email address and password. First time users will be prompted to set up a password.
C Q O fresnodbh.my.logicmanager.com/Iogi,T
LogicManager
Forgot your password?
Once logged in,the main screen will show reviewer task (incidents to review). Click on analyst/supervisor follow up
to view the incident.
LogicManager puns
Your Task List
TASK NAME SOURCE >TATUS 41511,VED TO
Exhibit H - Page 8 of 10
This screen below will then pop up. There are 5 tabs to navigate through. Client information will show the client and
facility information. No edits can be made to this section.
Analyst Follow Up
T,., CUeM rnbmxio�
M,me a rxnlry'
r3�zaraegwnnl,aM'
ExilkyaM�xs
Mental warm o�suCiuna Ix an�ax vmEr,m!'
[Dent MiOakrmdar
W ID.L3 xurtr-1o3.nWl to ` -n NCEL ._r
The next tab is Sum ary: No edits can be made to this section.
Analyst Follow Up
wq�rt.�
rncMenL IcnxY arl Mx appyl'
O�Ix MLYxx Y
rr Mnee-wxM D t.rnE pasonnq,m�eemrt ouIDreaai,xnb wlaxropncs;eveMs iEx AOwrei[e[M1e w<Irar<ane vrtty ur tl Tun aM/or mem0xs oltnecommnmlYl-
Daxeimwn nrma�I,<m.M•
B I V 5 Il = = / i ? s s B Q 9 C
r
Dxeormemem�
3anamla
r
Tarts ID'.3135a0rce',103'.null x C 3 a CaxCE[
Exhibit H - Page 9 of 10
The next tab is Follow up: This section can be edited. Add to the areas below or make corrections to these fields. Be
sure to click SAVE w en edits are made.Then Cancel to Exi ut of the incident.
Analyst Follow Up
"ID"-, orem i summary Follow Dp Documents
Acton Taken I<neck,It tn,[,pD1Y1'
Law Eniprcwnenscontactee lc -
Please specify if otlxr
Des<npuon of Acuon TaNen'
f
,eaea mrormaeon
copse of e<mn-t,n«r v<rc«prwr 3o-31a�
Task ID:313 SWrc!'LD3:nul1 u < I O
The next tab is Documents: View and add attachments to the incident. Be sure to click SAVE when adding
documents.Then Cancel to Exit out of the incident.
Analyst Follow Up x
Task Details Client Information Summary Follow Up Documents
- Q Add Document "
Name Type Source Upload Date Uploaded By
,11N�
No documents yet.
Drop files here or click on the Add Document dropdown.
« < > » CANCEL SAVE
Task ID:313 Source:103:null
If all tasks are followed up with and the incident no longer needs further review/information, click SUBMIT. Once
submitted,the incident will be removed from the task list and no further edits can be made. Notice the SUBMIT
button is on every tab. If further information needs to be included, email
DBHlncidentReporting@fresnocountyca.gov
Exhibit H - Page 10 of 10
To get back to the home view, click on the LID is Manager icon at any time. Any incidents that still need review will
show on this screen, click o x incident and start the review process again.
Your Task Lis[
TASK NAME souFcE 1TAT15 ASS IANIDTO :.SSiLNfU gy
Exhibit I - Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws, regulations,
rules and guidelines that apply to the provision and payment of mental health services. Mental
health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, Contractor, Contractor' 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, persons served, 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 I - 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 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 I - Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guideline s. 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 J - Page 1 of 8
Data Security
1. Definitions
Capitalized terms used in this Exhibit have the meanings set forth in this section 1.
(A) "Authorized Employees" means the Contractor's employees who have access to
Personal Information.
(B) "Authorized Persons" means: (i) any and all Authorized Employees; and (ii)any and all
of the Contractor's subcontractors, representatives, agents, outsourcers, and
consultants, and providers of professional services to the Contractor, who have access
to Personal Information and are bound by law or in writing by confidentiality obligations
sufficient to protect Personal Information in accordance with the terms of this Exhibit L.
(C) "Director" means the County's Director of the Department of Behavioral Health or his or
her designee.
(D) "Disclose" or any derivative of that word means to disclose, release, transfer,
disseminate, or otherwise provide access to or communicate all or any part of any
Personal Information orally, in writing, or by electronic or any other means to any person.
(E) "Person" means any natural person, corporation, partnership, limited liability company,
firm, or association.
(F) "Personal Information" means any and all information, including any data, provided, or
to which access is provided, to the Contractor by or upon the authorization of the
County, under this Agreement, including but not limited to vital records, that: (i) identifies,
describes, or relates to, or is associated with, or is capable of being used to identify,
describe, or relate to, or associate with, a person (including, without limitation, names,
physical descriptions, signatures, addresses, telephone numbers, e-mail addresses,
education, financial matters, employment history, and other unique identifiers, as well as
statements made by or attributable to the person); (ii) is used or is capable of being used
to authenticate a person (including, without limitation, employee identification numbers,
government-issued identification numbers, passwords or personal identification numbers
(PINs), financial account numbers, credit report information, answers to security
questions, and other personal identifiers); or (iii) is personal information within the
meaning of California Civil Code section 1798.3, subdivision (a), or 1798.80, subdivision
(e). Personal Information does not include publicly available information that is lawfully
made available to the general public from federal, state, or local government records.
(G)"Privacy Practices Complaint" means a complaint received by the County relating to
the Contractor's (or any Authorized Person's) privacy practices, or alleging a Security
Breach. Such complaint shall have sufficient detail to enable the Contractor to promptly
investigate and take remedial action under this Exhibit L.
(H) "Security Safeguards" means physical, technical, administrative or organizational
security procedures and practices put in place by the Contractor (or any Authorized
Persons)that relate to the protection of the security, confidentiality, value, or integrity of
Personal Information. Security Safeguards shall satisfy the minimal requirements set
forth in section 3(C) of this Exhibit L.
Exhibit J - Page 2 of 8
(1) "Security Breach" means (i) any act or omission that compromises either the security,
confidentiality, value, or integrity of any Personal Information or the Security Safeguards,
or (ii) any unauthorized Use, Disclosure, or modification of, or any loss or destruction of,
or any corruption of or damage to, any Personal Information.
(J) "Use" or any derivative of that word means to receive, acquire, collect, apply,
manipulate, employ, process, transmit, disseminate, access, store, disclose, or dispose
of Personal Information.
2. Standard of Care
(A) The Contractor acknowledges that, in the course of its engagement by the County under
this Agreement, the Contractor, or any Authorized Persons, may Use Personal
Information only as permitted in this Agreement.
(B) The Contractor acknowledges that Personal Information is deemed to be confidential
information of, or owned by, the County (or persons from whom the County receives or
has received Personal Information) and is not confidential information of, or owned or by,
the Contractor, or any Authorized Persons. The Contractor further acknowledges that all
right, title, and interest in or to the Personal Information remains in the County (or
persons from whom the County receives or has received Personal Information)
regardless of the Contractor's, or any Authorized Person's, Use of that Personal
Information.
(C) The Contractor agrees and covenants in favor of the Country that the Contractor shall:
(i) keep and maintain all Personal Information in strict confidence, using such
degree of care under this section 2 as is reasonable and appropriate to avoid a
Security Breach;
(ii) Use Personal Information exclusively for the purposes for which the Personal
Information is made accessible to the Contractor pursuant to the terms of this
Exhibit L;
(iii) not Use, Disclose, sell, rent, license, or otherwise make available Personal
Information for the Contractor's own purposes or for the benefit of anyone other
than the County, without the County's express prior written consent, which the
County may give or withhold in its sole and absolute discretion; and
(iv) not, directly or indirectly, Disclose Personal Information to any person (an
"Unauthorized Third Party") other than Authorized Persons pursuant to this
Agreement, without the Director's express prior written consent.
(D) Notwithstanding the foregoing paragraph, in any case in which the Contractor believes it,
or any Authorized Person, is required to disclose Personal Information to government
regulatory authorities, or pursuant to a legal proceeding, or otherwise as may be
required by applicable law, Contractor shall (i) immediately notify the County of the
specific demand for, and legal authority for the disclosure, including providing County
with a copy of any notice, discovery demand, subpoena, or order, as applicable,
received by the Contractor, or any Authorized Person, from any government regulatory
authorities, or in relation to any legal proceeding, and (ii) promptly notify the County
Exhibit J - Page 3 of 8
before such Personal Information is offered by the Contractor for such disclosure so that
the County may have sufficient time to obtain a court order or take any other action the
County may deem necessary to protect the Personal Information from such disclosure,
and the Contractor shall cooperate with the County to minimize the scope of such
disclosure of such Personal Information.
(E) The Contractor shall remain liable to the County for the actions and omissions of any
Unauthorized Third Party concerning its Use of such Personal Information as if they
were the Contractor's own actions and omissions.
3. Information Security
(A) The Contractor covenants, represents and warrants to the County that the Contractor's
Use of Personal Information under this Agreement does and will at all times comply with
all applicable federal, state, and local, privacy and data protection laws, as well as all
other applicable regulations and directives, including but not limited to California Civil
Code, Division 3, Part 4, Title 1.81 (beginning with section 1798.80), and the Song-
Beverly Credit Card Act of 1971 (California Civil Code, Division 3, Part 4, Title 1.3,
beginning with section 1747). If the Contractor Uses credit, debit or other payment
cardholder information, the Contractor shall at all times remain in compliance with the
Payment Card Industry Data Security Standard ("PCI DSS") requirements, including
remaining aware at all times of changes to the PCI DSS and promptly implementing and
maintaining all procedures and practices as may be necessary to remain in compliance
with the PCI DSS, in each case, at the Contractor's sole cost and expense.
(B) The Contractor covenants, represents and warrants to the County that, as of the
effective date of this Agreement, the Contractor has not received notice of any violation
of any privacy or data protection laws, as well as any other applicable regulations or
directives, and is not the subject of any pending legal action or investigation by, any
government regulatory authority regarding same.
(C) Without limiting the Contractor's obligations under section 3(A) of this Exhibit L, the
Contractor's (or Authorized Person's) Security Safeguards shall be no less rigorous than
accepted industry practices and, at a minimum, include the following:
(i) limiting Use of Personal Information strictly to the Contractor's and Authorized
Persons' technical and administrative personnel who are necessary for the
Contractor's, or Authorized Persons', Use of the Personal Information pursuant to
this Agreement;
(ii) ensuring that all of the Contractor's connectivity to County computing systems
will only be through the County's security gateways and firewalls, and only
through security procedures approved upon the express prior written consent of
the Director;
(iii) to the extent that they contain or provide access to Personal Information, (a)
securing business facilities, data centers, paper files, servers, back-up systems
and computing equipment, operating systems, and software applications,
including, but not limited to, all mobile devices and other equipment, operating
systems, and software applications with information storage capability; (b)
Exhibit J - Page 4 of 8
employing adequate controls and data security measures, both internally and
externally, to protect (1) the Personal Information from potential loss or
misappropriation, or unauthorized Use, and (2) the County's operations from
disruption and abuse; (c) having and maintaining network, device application,
database and platform security; (d) maintaining authentication and access
controls within media, computing equipment, operating systems, and software
applications; and (e) installing and maintaining in all mobile, wireless, or
handheld devices a secure internet connection, having continuously updated
anti-virus software protection and a remote wipe feature always enabled, all of
which is subject to express prior written consent of the Director;
(iv) encrypting all Personal Information at advance encryption standards of Advanced
Encryption Standards (AES) of 128 bit or higher (a) stored on any mobile
devices, including but not limited to hard disks, portable storage devices, or
remote installation, or (b) transmitted over public or wireless networks (the
encrypted Personal Information must be subject to password or pass phrase, and
be stored on a secure server and transferred by means of a Virtual Private
Network (VPN) connection, or another type of secure connection, all of which is
subject to express prior written consent of the Director);
(v) strictly segregating Personal Information from all other information of the
Contractor, including any Authorized Person, or anyone with whom the
Contractor or any Authorized Person deals so that Personal Information is not
commingled with any other types of information;
(vi) having a patch management process including installation of all operating system
and software vendor security patches;
(vii) maintaining appropriate personnel security and integrity procedures and
practices, including, but not limited to, conducting background checks of
Authorized Employees consistent with applicable law; and
(viii) providing appropriate privacy and information security training to Authorized
Employees.
(D) During the term of each Authorized Employee's employment by the Contractor, the
Contractor shall cause such Authorized Employees to abide strictly by the Contractor's
obligations under this Exhibit L. The Contractor shall maintain a disciplinary process to
address any unauthorized Use of Personal Information by any Authorized Employees.
(E) The Contractor shall, in a secure manner, backup daily, or more frequently if it is the
Contractor's practice to do so more frequently, Personal Information received from the
County, and the County shall have immediate, real time access, at all times, to such
backups via a secure, remote access connection provided by the Contractor, through the
Internet.
(F) The Contractor shall provide the County with the name and contact information for each
Authorized Employee (including such Authorized Employee's work shift, and at least one
alternate Authorized Employee for each Authorized Employee during such work shift)
who shall serve as the County's primary security contact with the Contractor and shall be
Exhibit J - Page 5 of 8
available to assist the County twenty-four (24) hours per day, seven (7) days per week
as a contact in resolving the Contractor's and any Authorized Persons' obligations
associated with a Security Breach or a Privacy Practices Complaint.
(G)The Contractor shall not knowingly include or authorize any Trojan Horse, back door,
time bomb, drop dead device, worm, virus, or other code of any kind that may disable,
erase, display any unauthorized message within, or otherwise impair any County
computing system, with or without the intent to cause harm.
4. Security Breach Procedures
(A) Immediately upon the Contractor's awareness or reasonable belief of a Security Breach,
the Contractor shall (i) notify the Director of the Security Breach, such notice to be given
first by telephone at the following telephone number, followed promptly by email at the
following email addresses: incidents(a�_fresnocountyca.gov, 559-600-5900, (559) 600-
4645, dbhcontractedservices(a)fresnocountyca.gov,
dbhforensicservices(a-)_fresnocountyca.gov (which telephone number and email address
the County may update by providing notice to the Contractor), and (ii) preserve all
relevant evidence (and cause any affected Authorized Person to preserve all relevant
evidence) relating to the Security Breach. The notification shall include, to the extent
reasonably possible, the identification of each type and the extent of Personal
Information that has been, or is reasonably believed to have been, breached, including
but not limited to, compromised, or subjected to unauthorized Use, Disclosure, or
modification, or any loss or destruction, corruption, or damage.
(B) Immediately following the Contractor's notification to the County of a Security Breach, as
provided pursuant to section 4(A) of this Exhibit L, the Parties shall coordinate with each
other to investigate the Security Breach. The Contractor agrees to fully cooperate with
the County, including, without limitation:
(i) assisting the County in conducting any investigation;
(ii) providing the County with physical access to the facilities and operations
affected;
(iii) facilitating interviews with Authorized Persons and any of the Contractor's other
employees knowledgeable of the matter; and
(iv) making available all relevant records, logs, files, data reporting and other
materials required to comply with applicable law, regulation, industry standards,
or as otherwise reasonably required by the County.
To that end, the Contractor shall, with respect to a Security Breach, be solely
responsible, at its cost, for all notifications required by law and regulation, or deemed
reasonably necessary by the County, and the Contractor shall provide a written report of
the investigation and reporting required to the Director within 30 days after the
Contractor's discovery of the Security Breach.
(C) County shall promptly notify the Contractor of the Director's knowledge, or reasonable
belief, of any Privacy Practices Complaint, and upon the Contractor's receipt of that
notification, the Contractor shall promptly address such Privacy Practices Complaint,
Exhibit J - Page 6 of 8
including taking any corrective action under this Exhibit L, all at the Contractor's sole
expense, in accordance with applicable privacy rights, laws, regulations and standards.
In the event the Contractor discovers a Security Breach, the Contractor shall treat the
Privacy Practices Complaint as a Security Breach. Within 24 hours of the Contractor's
receipt of notification of such Privacy Practices Complaint, the Contractor shall notify the
County whether the matter is a Security Breach, or otherwise has been corrected and
the manner of correction, or determined not to require corrective action and the reason
for that determination.
(D) The Contractor shall take prompt corrective action to respond to and remedy any
Security Breach and take mitigating actions, including but not limiting to, preventing any
reoccurrence of the Security Breach and correcting any deficiency in Security
Safeguards as a result of such incident, all at the Contractor's sole expense, in
accordance with applicable privacy rights, laws, regulations and standards. The
Contractor shall reimburse the County for all reasonable costs incurred by the County in
responding to, and mitigating damages caused by, any Security Breach, including all
costs of the County incurred relation to any litigation or other action described section
4(E) of this Exhibit L.
(E) The Contractor agrees to cooperate, at its sole expense, with the County in any litigation
or other action to protect the County's rights relating to Personal Information, including
the rights of persons from whom the County receives Personal Information.
5. Oversight of Security Compliance
(A) The Contractor shall have and maintain a written information security policy that
specifies Security Safeguards appropriate to the size and complexity of the Contractor's
operations and the nature and scope of its activities.
(B) Upon the County's written request, to confirm the Contractor's compliance with this
Exhibit L, as well as any applicable laws, regulations and industry standards, the
Contractor grants the County or, upon the County's election, a third party on the
County's behalf, permission to perform an assessment, audit, examination or review of
all controls in the Contractor's physical and technical environment in relation to all
Personal Information that is Used by the Contractor pursuant to this Agreement. The
Contractor shall fully cooperate with such assessment, audit or examination, as
applicable, by providing the County or the third party on the County's behalf, access to
all Authorized Employees and other knowledgeable personnel, physical premises,
documentation, infrastructure and application software that is Used by the Contractor for
Personal Information pursuant to this Agreement. In addition, the Contractor shall
provide the County with the results of any audit by or on behalf of the Contractor that
assesses the effectiveness of the Contractor's information security program as relevant
to the security and confidentiality of Personal Information Used by the Contractor or
Authorized Persons during the course of this Agreement under this Exhibit L.
(C) The Contractor shall ensure that all Authorized Persons who Use Personal Information
agree to the same restrictions and conditions in this Exhibit L. that apply to the
Contractor with respect to such Personal Information by incorporating the relevant
provisions of these provisions into a valid and binding written agreement between the
Exhibit J - Page 7 of 8
Contractor and such Authorized Persons, or amending any written agreements to
provide same.
6. Return or Destruction of Personal Information. Upon the termination of this Agreement,
the Contractor shall, and shall instruct all Authorized Persons to, promptly return to the County
all Personal Information, whether in written, electronic or other form or media, in its possession
or the possession of such Authorized Persons, in a machine readable form used by the County
at the time of such return, or upon the express prior written consent of the Director, securely
destroy all such Personal Information, and certify in writing to the County that such Personal
Information have been returned to the County or disposed of securely, as applicable. If the
Contractor is authorized to dispose of any such Personal Information, as provided in this Exhibit
L, such certification shall state the date, time, and manner (including standard) of disposal and
by whom, specifying the title of the individual. The Contractor shall comply with all reasonable
directions provided by the Director with respect to the return or disposal of Personal Information
and copies of Personal Information. If return or disposal of such Personal Information or copies
of Personal Information is not feasible, the Contractor shall notify the County according,
specifying the reason, and continue to extend the protections of this Exhibit L to all such
Personal Information and copies of Personal Information. The Contractor shall not retain any
copy of any Personal Information after returning or disposing of Personal Information as
required by this section 6. The Contractor's obligations under this section 6 survive the
termination of this Agreement and apply to all Personal Information that the Contractor retains if
return or disposal is not feasible and to all Personal Information that the Contractor may later
discover.
7. Equitable Relief. The Contractor acknowledges that any breach of its covenants or
obligations set forth in this Exhibit L may cause the County irreparable harm for which monetary
damages would not be adequate compensation and agrees that, in the event of such breach or
threatened breach, the County is entitled to seek equitable relief, including a restraining order,
injunctive relief, specific performance and any other relief that may be available from any court,
in addition to any other remedy to which the County may be entitled at law or in equity. Such
remedies shall not be deemed to be exclusive but shall be in addition to all other remedies
available to the County at law or in equity or under this Agreement.
8. Indemnity. The Contractor shall defend, indemnify and hold harmless the County, its
officers, employees, and agents, (each, a "County Indemnitee") from and against any and all
infringement of intellectual property including, but not limited to infringement of copyright,
trademark, and trade dress, invasion of privacy, information theft, and extortion, unauthorized
Use, Disclosure, or modification of, or any loss or destruction of, or any corruption of or damage
to, Personal Information, Security Breach response and remedy costs, credit monitoring
expenses, forfeitures, losses, damages, liabilities, deficiencies, actions, judgments, interest,
awards, fines and penalties (including regulatory fines and penalties), costs or expenses of
whatever kind, including attorneys' fees and costs, the cost of enforcing any right to
indemnification or defense under this Exhibit L and the cost of pursuing any insurance
providers, arising out of or resulting from any third party claim or action against any County
Indemnitee in relation to the Contractor's, its officers, employees, or agents, or any Authorized
Employee's or Authorized Person's, performance or failure to perform under this Exhibit L or
arising out of or resulting from the Contractor's failure to comply with any of its obligations under
this section 8. The provisions of this section 8 do not apply to the acts or omissions of the
Exhibit J - Page 8 of 8
County. The provisions of this section 8 are cumulative to any other obligation of the Contractor
to, defend, indemnify, or hold harmless any County Indemnitee under this Agreement. The
provisions of this section 8 shall survive the termination of this Agreement.
9. Survival. The respective rights and obligations of the Contractor and the County as stated
in this Exhibit L shall survive the termination of this Agreement.
10. No Third Party Beneficiary. Nothing express or implied in the provisions of in this Exhibit L
is intended to confer, nor shall anything in this Exhibit L confer, upon any person other than the
County or the Contractor and their respective successors or assignees, any rights, remedies,
obligations or liabilities whatsoever.
11. No County Warranty. The County does not make any warranty or representation whether
any Personal Information in the Contractor's (or any Authorized Person's) possession or control,
or Use by the Contractor (or any Authorized Person), pursuant to the terms of this Agreement is
or will be secure from unauthorized Use, or a Security Breach or Privacy Practices Complaint.
Exhibit K- Page 1 of 2
Self-Dealing Transaction Disclosure Form
In order to conduct business with the County of Fresno ("County"), members of a
contractor's board of directors ("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 used 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.
The form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit K- Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a
party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of
Corporations Code § 5233 (a)
(5)Authorized Signature
Signature: Date:
Exhibit L- Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address(number,street) City State ZIP code
CILIA 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.
YES NO
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
by Titles XVI II,XIX,or XX? ......................................................................................................................... n n
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 XVI II,XIX,or XX?...................................................................................... o 0
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 XVII I providers only)........... o 0
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: o Sole proprietorship o Partnership o Corporation
o Unincorporated Associations o 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........................................................................................................... o n
NAME ADDRESS PROVIDER NUMBER
Exhibit L- Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... o 0
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... o 0
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ o 0
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... o 0
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?......... o 0
VII. A. Is this facility chain affiliated? ...................................................................................................................... n n
If yes, list name,address of corporation,and EIN.
Name EIN
Address(number,name) City State ZIP code
B. If the answer to question VII.A. is NO,was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address(number,name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative(typed) Title
Signature Date
Remarks
Exhibit M - Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
2. The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant shall
submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this
clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which
this proposal is being submitted for assistance in obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
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 M - 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 N - Page 1 of 2
1
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help
eliminate health care disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
l. Provide effective,equitable,understandable,and respectful quality care and services that are responsive to diverse cultural health beliefs and
practices, preferred languages,health literacy,and other communication needs.
Governance,Leadership,and Workforce:
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,practices,and
allocated resources.
3. Recruit,promote,and support a culturally and linguistically diverse governance,leadership,and workforce that are responsive to the population in
the service area.
4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance:
S. Offer language assistance to individuals who have limited English proficiency and/or other communication needs,at no cost to them,to facilitate
timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their preferred language,verbally and in writing.
7. Ensure the competence of individuals providing language assistance,recognizing that the use of untrained individuals and/or minors as interpreters
should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Engagement,Continuous Improvement,and Accountability:
9. Establish culturally and linguistically appropriate goals,policies,and management accountability,and infuse them throughout the organization's
planning and operations.
10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous
quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to
inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the
cultural and linguistic diversity of populations in the service area.
13. Partner with the community to design,implement,and evaluate policies,practices,and services to ensure cultural and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify,prevent,and resolve conflicts
or complaints.
15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders,constituents,and the general public.
\,L Think Cultural Health
�1 US.Department of https://www.thinkculturalhealth.hhs.gov/
{� //�� Health and Human Services
O1 Y 1 H Office of MinorityHeanh contact@thinkculturalhealth.hhs.gov
Exhibit N - Page 2 of 2
2
The Case for the National CLAS Standards
Health equity is the attainment of the highest level of health for all people.' Currently,individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons,including the social determinants of health,or those conditions in which
individuals are born,grow,live,work,and age,' such as socioeconomic status,education level,and the availability of health services.3
Though health inequities are directly related to the existence of historical and current discrimination
and social injustice,one of the most modifiable factors is the lack of culturally and linguistically
appropriate services,broadly defined as care and services that are respectful of and responsive to
the cultural and linguistic needs of all individuals.
Of all the forms of
Health inequities result in disparities that directly affect the quality of life for all individuals.Health
disparities adversely affect neighborhoods,communities,and the broader society,thus making inequality, injustice in
the issue not only an individual concern but also a public health concern. In the United States,it health care is the most
has been estimated that the combined cost of health disparities and subsequent deaths due to shocking and inhumane.
inadequate and/or inequitable care is$1.24 trillion.°
Culturally and linguistically appropriate services are increasingly recognized as effective in improving —Dr.Martin Luther King,Jr.
the quality of care and services.s,6 By providing a structure to implement culturally and linguistically
appropriate services,the National CLAS Standards will improve an organization's ability to address
health care disparities.
The National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities'and the National Stakeholder Strategy for
Achieving Health Equity,'which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial
and ethnic health disparities across the country.
Similar to these initiatives,the National CLAS Standards are intended to advance health equity,improve quality,and help eliminate health care disparities
by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. Adoption of
these Standards will help advance better health and health care in the United States.
Bibliography
1.U.S.Department of Health and Human Services,Office of Minority Health(2011).National Partnership for Action to End Health Disparities.Retrieved from http://minorityhealth.hhs.gov/npa
2.World Health Organization.(2012).Social determinants of health.Retrieved from http://www.who.int/social_determinants/en/
3. U.S.Department of Health and Human Services,Office of Disease Prevention and Health Promotion.(2010).Healthy people 2020:Social determinants of health.Retrieved from http://www.
h ealthypeopl e.gov/2020/topics objectives2O2O/overview.as px.7topicid=3 9
4. LaVeist,T.A.,Gaskin,D.J.,&Richard,P.(2009).The economic burden of health inequalities in the United States.Retrieved from the Joint Center for Political and Economic Studies website:http://www.
jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2 OBurden%20of%2OHealth%201nequalities%20in%20the%2OUnited%20States.pdf
5. Beach,M.C.,Cooper,L.A.,Robinson,K.A.,Price,E.G.,Gary,T.L.,Jenckes,M.W.,Powe,N.R.(2004).Strategies for improving minority healthcare quality.(AHRQ Publication No.04-EO08-02).Retrieved
from the Agency of Healthcare Research and Quality website:http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf
6.Goode,T.D.,Dunne,M.C.,&Bronheim,S.M.(2006).The evidence base for cultural and linguistic competency in health care.(Commonwealth Fund Publication No.962).Retrieved from The
Commonwealth Fund website:http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultiinguisticcomp_962.pdf
7. U.S.Department of Health and Human Services.(2011).HHS action plan to reduce racial and ethnic health disparities:A nation free of disparities in health and health care.Retrieved from http://
minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan complete.pdf
8. National Partnership for Action to End Health Disparities.(2011).National stakeholder strategy for achieving health equity.Retrieved from U.S.Department of Health and Human Services,Office of
Minority Health website:http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
Think Cultural Health
�1 US.Department of https://www.thinkculturalhealth.hhs.gov/
{� //�� Health and Human Services
O1 Y 1 H Office of MinorityHeanh contact@thinkculturalhealth.hhs.gov
Exhibit O-Page 1 of 9
Health Insurance Portability and Accountability Act (HIPAA)
Business Associate Agreement
1. The County is a "Covered Entity," and the Contractor is a "Business Associate,"
as these terms are defined by 45 CFR 160.103. In connection with providing services under the
Agreement, the parties anticipate that the Contractor will create and/or receive Protected Health
Information ("PHI") from or on behalf of the County. The parties enter into this Business
Associate Agreement (BAA) to comply with the Business Associate requirements of HIPAA, to
govern the use and disclosures of PHI under this Agreement. "HIPAA Rules" shall mean the
Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Parts 160 and 164.
The parties to this Agreement shall be in strict conformance with all applicable federal
and State of California laws and regulations, including, but not limited to California Welfare and
Institutions Code sections 5328, 10850, and 14100.2 et seq.; 42 CFR 2; 42 CFR 431; California
Civil Code section 56 et seq.; the Health Insurance Portability and Accountability Act of 1996, as
amended ("HIPAA"), including, but not limited to, 45 CFR Parts160, 45 CFR 162, and 45 CFR
164; the Health Information Technology for Economic and Clinical Health Act ("HITECH")
regarding the confidentiality and security of patient information, including, but not limited to 42
USC 17901 et seq.; and the Genetic Information Nondiscrimination Act ("GINA") of 2008
regarding the confidentiality of genetic information.
Except as otherwise provided in this Agreement, the Contractor, as a business associate
of the County, may use or disclose Protected Health Information ("PHI") to perform functions,
activities or services for or on behalf of the County, as specified in this Agreement, provided that
such use or disclosure shall not violate HIPAA Rules. The uses and disclosures of PHI may not
be more expansive than those applicable to the County, as the "Covered Entity" under the
HIPAA Rules, except as authorized for management, administrative or legal responsibilities of
the Contractor.
2. The Contractor, including its subcontractors and employees, shall protect from
unauthorized access, use, or disclosure of names and other identifying information, including
genetic information, concerning persons receiving services pursuant to this Agreement, except
Exhibit O-Page 2 of 9
where permitted in order to carry out data aggregation purposes for health care operations [45
CFR §§ 164.504(e)(2)(i), 164.504(e)(2)(ii)(A), and 164.504(e)(4)(i)]. This pertains to any and all
persons receiving services pursuant to a County-funded program. This requirement applies to
electronic PHI. The Contractor shall not use such identifying information or genetic information
for any purpose other than carrying out the Contractor's obligations under this Agreement.
3. The Contractor, including its subcontractors and employees, shall not disclose
any such identifying information or genetic information to any person or entity, except as
otherwise specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164
or other law, required by the Secretary of the United States Department of Health and Human
Services ("Secretary"), or authorized by the client/patient in writing. In using or disclosing PHI
that is permitted by this Agreement or authorized by law, the Contractor shall make reasonable
efforts to limit PHI to the minimum necessary to accomplish intended purpose of use, disclosure
or request.
4. For purposes of the above sections, identifying information shall include, but not
be limited to, name, identifying number, symbol, or other identifying particular assigned to the
individual, such as fingerprint or voiceprint, or photograph.
5. For purposes of the above sections, genetic information shall include genetic
tests of family members of an individual or individual(s), manifestation of disease or disorder of
family members of an individual, or any request for or receipt of genetic services by individual or
family members. Family member means a dependent or any person who is first, second, third,
or fourth degree relative.
6. The Contractor shall provide access, at the request of the County, and in the time
and manner designated by the County, to PHI in a designated record set (as defined in 45 CFR
§ 164.501), to an individual or to COUNTY in order to meet the requirements of 45 CFR §
164.524 regarding access by individuals to their PHI. With respect to individual requests,
access shall be provided within thirty (30) days from request. Access may be extended if the
Contractor cannot provide access and provides the individual with the reasons for the delay and
Exhibit O-Page 3 of 9
the date when access may be granted. PHI shall be provided in the form and format requested
by the individual or the County.
The Contractor shall make any amendment(s) to PHI in a designated record set at the
request of the County or individual, and in the time and manner designated by the County in
accordance with 45 CFR § 164.526.
The Contractor shall provide to the County or to an individual, in a time and manner
designated by the County, information collected in accordance with 45 CFR § 164.528, to permit
the County to respond to a request by the individual for an accounting of disclosures of PHI in
accordance with 45 CFR § 164.528.
7. The Contractor shall report to the County, in writing, any knowledge or
reasonable belief that there has been unauthorized access, viewing, use, disclosure, security
incident, or breach of unsecured PHI not permitted by this Agreement of which the Contractor
becomes aware, immediately and without reasonable delay and in no case later than two (2)
business days of discovery. Immediate notification shall be made to the County's Information
Security Officer and Privacy Officer and the County's Department of Public Health ("DPH")
HIPAA Representative, within two (2) business days of discovery. The notification shall include,
to the extent possible, the identification of each individual whose unsecured PHI has been, or is
reasonably believed to have been, accessed, acquired, used, disclosed, or breached. The
Contractor shall take prompt corrective action to cure any deficiencies and any action pertaining
to such unauthorized disclosure required by applicable federal and State laws and regulations.
The Contractor shall investigate such breach and is responsible for all notifications required by
law and regulation or deemed necessary by the County and shall provide a written report of the
investigation and reporting required to the County's Information Security Officer and Privacy
Officer and the County's DPH HIPAA Representative.
This written investigation and description of any reporting necessary shall be
postmarked within the thirty (30) working days of the discovery of the breach to the addresses
below:
Exhibit O-Page 4 of 9
County of Fresno County of Fresno County of Fresno
Department of Public Health Department of Public Health Department of Internal
HIPAA Representative Privacy Officer Services
(559) 600-6439 (559) 600-6405 Information Security Officer
P.O. Box 11867 P.O. Box 11867 (559) 600-5800
Fresno, California 93775 Fresno, California 93775 2048 North Fine Street
Fresno, California 93727
8. The Contractor shall make its internal practices, books, and records relating to
the use and disclosure of PHI received from the county, or created or received by the Contractor
on behalf of the County, in compliance with Parts the HIPAA Rules. The Contractor shall make
its internal practices, books, and records relating to the use and disclosure of PHI received from
the County, or created or received by the Contractor on behalf of the County, available to the
Secretary upon demand.
The Contractor shall cooperate with the compliance and investigation reviews conducted
by the Secretary. PHI access to the Secretary must be provided during the Contractor's normal
business hours; however, upon exigent circumstances access at any time must be granted.
Upon the Secretary's compliance or investigation review, if PHI is unavailable to the Contractor
and in possession of a subcontractor of the Contractor, the Contractor must certify to the
Secretary its efforts to obtain the information from the subcontractor.
9. Safeguards
The Contractor shall implement administrative, physical, and technical safeguards as
required by the HIPAA Security Rule, Subpart C of 45 CFR Part 164, that reasonably and
appropriately protect the confidentiality, integrity, and availability of PHI, including electronic
PHI, that it creates, receives, maintains or transmits on behalf of the County and to prevent
unauthorized access, viewing, use, disclosure, or breach of PHI other than as provided for by
this Agreement. The Contractor shall conduct an accurate and thorough assessment of the
potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic PHI.
The Contractor shall develop and maintain a written information privacy and security program
that includes administrative, technical and physical safeguards appropriate to the size and
complexity of the Contractor's operations and the nature and scope of its activities. Upon the
County's request, the Contractor shall provide the County with information concerning such
Exhibit O-Page 5 of 9
safeguards.
The Contractor shall implement strong access controls and other security safeguards
and precautions in order to restrict logical and physical access to confidential, personal (e.g.,
PHI) or sensitive data to authorized users only. Said safeguards and precautions shall include
the following administrative and technical password controls for all systems used to process or
store confidential, personal, or sensitive data:
A. Passwords must not be:
(1) Shared or written down where they are accessible or recognizable by anyone
else; such as taped to computer screens, stored under keyboards, or visible
in a work area;
(2) A dictionary word; or
(3) Stored in clear text
B. Passwords must be:
(1) Eight (8) characters or more in length;
(2) Changed every ninety (90) days;
(3) Changed immediately if revealed or compromised; and
(4) Composed of characters from at least three (3) of the following four (4)
groups from the standard keyboard:
a) Upper case letters (A-Z);
b) Lowercase letters (a-z);
c) Arabic numerals (0 through 9); and
d) Non-alphanumeric characters (punctuation symbols).
The Contractor shall implement the following security controls on each workstation or
portable computing device (e.g., laptop computer) containing confidential, personal, or sensitive
data:
1. Network-based firewall and/or personal firewall;
2. Continuously updated anti-virus software; and
3. Patch management process including installation of all operating system/software
Exhibit O-Page 6 of 9
vendor security patches.
The Contractor shall utilize a commercial encryption solution that has received RIPS
140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable
electronic media (including, but not limited to, compact disks and thumb drives) and on portable
computing devices (including, but not limited to, laptop and notebook computers).
The Contractor shall not transmit confidential, personal, or sensitive data via e-mail or
other internet transport protocol unless the data is encrypted by a solution that has been
validated by the National Institute of Standards and Technology (NIST) as conforming to the
Advanced Encryption Standard (AES) Algorithm. The Contractor must apply appropriate
sanctions against its employees who fail to comply with these safeguards. The Contractor must
adopt procedures for terminating access to PHI when employment of employee ends.
10. Mitigation of Harmful Effects
The Contractor shall mitigate, to the extent practicable, any harmful effect that is
suspected or known to the Contractor of an unauthorized access, viewing, use, disclosure, or
breach of PHI by the Contractor or its subcontractors in violation of the requirements of these
provisions. The Contractor must document suspected or known harmful effects and the
outcome.
11. The Contractor's Subcontractors
The Contractor shall ensure that any of its contractors, including subcontractors, if
applicable, to whom the Contractor provides PHI received from or created or received by the
Contractor on behalf of the County, agree to the same restrictions, safeguards, and conditions
that apply to the Contractor with respect to such PHI and to incorporate, when applicable, the
relevant provisions of these provisions into each subcontract or sub-award to such agents or
subcontractors.
Nothing in this section 11 or this exhibit authorizes the Contractor to perform services
under this Agreement using subcontractors.
12. Employee Training and Discipline
The Contractor shall train and use reasonable measures to ensure compliance with the
Exhibit O-Page 7 of 9
requirements of these provisions by employees who assist in the performance of functions or
activities on behalf of the County under this Agreement and use or disclose PHI, and discipline
such employees who intentionally violate any provisions of these provisions, which may include
termination of employment.
13. Termination for Cause
Upon the County's knowledge of a material breach of these provisions by the Contractor,
the County will either:
A. Provide an opportunity for the Contractor to cure the breach or end the
violation, and the County may terminate this Agreement if the Contractor does not cure the
breach or end the violation within the time specified by the County; or
B. Immediately terminate this Agreement if the Contractor has breached a
material term of this exhibit and cure is not possible, as determined by the County.
C. If neither cure nor termination is feasible, the County's Privacy Officer will
report the violation to the Secretary of the U.S. Department of Health and Human Services.
14. Judicial or Administrative Proceedings
The County may terminate this Agreement if: (1) the Contractor is found guilty in a
criminal proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act; or
(2) there is a finding or stipulation in an administrative or civil proceeding in which the Contractor
is a party that the Contractor has violated a privacy or security standard or requirement of the
HITECH Act, HIPAA or other security or privacy laws.
15. Effect of Termination
Upon termination or expiration of this Agreement for any reason, the Contractor shall
return or destroy all PHI received from the County (or created or received by the Contractor on
behalf of the County) that the Contractor still maintains in any form, and shall retain no copies of
such PHI. If return or destruction of PHI is not feasible, the Contractor shall continue to extend
the protections of these provisions to such information, and limit further use of such PHI to those
purposes that make the return or destruction of such PHI infeasible. This provision applies to
PHI that is in the possession of subcontractors or agents, if applicable, of the Contractor. If the
Exhibit O-Page 8 of 9
Contractor destroys the PHI data, a certification of date and time of destruction shall be
provided to the County by the Contractor.
16. Compliance with Other Laws
To the extent that other state and/or federal laws provide additional, stricter and/or more
protective privacy and/or security protections to PHI or other confidential information covered
under this BAA, the Contractor agrees to comply with the more protective of the privacy and
security standards set forth in the applicable state or federal laws to the extent such standards
provide a greater degree of protection and security than HIPAA Rules or are otherwise more
favorable to the individual.
17. Disclaimer
The County makes no warranty or representation that compliance by the Contractor with
these provisions, the HITECH Act, or the HIPAA Rules, will be adequate or satisfactory for the
Contractor's own purposes or that any information in the Contractor's possession or control, or
transmitted or received by the Contractor, is or will be secure from unauthorized access,
viewing, use, disclosure, or breach. The Contractor is solely responsible for all decisions made
by the Contractor regarding the safeguarding of PHI.
18. Amendment
The parties acknowledge that Federal and State laws relating to electronic data security
and privacy are rapidly evolving and that amendment of this exhibit may be required to provide
for procedures to ensure compliance with such developments. The parties specifically agree to
take such action as is necessary to amend this agreement in order to implement the standards
and requirements of the HIPAA Rules, the HITECH Act and other applicable laws relating to the
security or privacy of PHI. The County may terminate this Agreement upon thirty (30) days
written notice in the event that the Contractor does not enter into an amendment providing
assurances regarding the safeguarding of PHI that the County in its sole discretion, deems
sufficient to satisfy the standards and requirements of the HIPAA Rules, and the HITECH Act.
19. No Third-Party Beneficiaries
Nothing expressed or implied in the provisions of this exhibit is intended to confer, and
Exhibit O-Page 9 of 9
nothing in this exhibit does confer, upon any person other than the County or the Contractor and
their respective successors or assignees, any rights, remedies, obligations or liabilities
whatsoever.
20. Interpretation
The provisions of this exhibit shall be interpreted as broadly as necessary to implement
and comply with the HIPAA Rules, and applicable State laws. The parties agree that any
ambiguity in the terms and conditions of these provisions shall be resolved in favor of a meaning
that complies and is consistent with the HIPAA Rules.
21. Regulatory References
A reference in the terms and conditions of these provisions to a section in the HIPAA
Rules means the section as in effect or as amended.
22. Survival
The respective rights and obligations of the Contractor as stated in this exhibit survive
the termination or expiration of this Agreement.
23. No Waiver of Obligation
Change, waiver or discharge by the County of any liability or obligation of the Contractor
under this exhibit on any one or more occasions is not a waiver of performance of any
continuing or other obligation of the Contractor and does not prohibit enforcement by the County
of any obligation on any other occasion.