HomeMy WebLinkAboutAgreement A-18-576.pdf Agreement No. 18-576
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 9th day of October , 2018,
3 by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
4 hereinafter referred to as "COUNTY", and CENTRAL STAR BEHAVIORAL HEALTH, INC., a for-profit
5 corporation, whose business address is 1501 Hughes Way, Suite 150, Long Beach, CA, 90810,
6 hereinafter referred to as "CONTRACTOR," collectively, "the parties."
7 WITNESSETH:
8 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a
9 qualified agency to operate a Mental Health Services Act (MHSA) Transition Age Youth (TAY) Mental
10 Health Services and Supports & Housing Services program to deliver integrated mental health and
11 supportive housing services to Transition Age Youth, ages 16 to 25 years of age, who are aging out of
12 Children's Mental health and require on-going services, who have a serious mental illness, and who
13 are aging out of Juvenile Justice System, and are at risk of being hospitalized, homeless, and/or
14 incarcerated; and
15 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is a Mental Health
16 Plan (MHP) as defined in Title 9 of the California Code of Regulations (C.C.R.), section 1810.226; and
17 WHEREAS, CONTRACTOR is qualified and willing to operate said Transition Age Youth Mental
18 Health Services & Supports & Housing Services Program pursuant to the terms and conditions of this
19 Agreement.
20 NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
21 hereto agree as follows:
22 1. SERVICES
23 A. CONTRACTOR shall perform all services and fulfill all responsibilities as set forth
24 in its Exhibit A, "Scope of Work", attached hereto and by this reference incorporated herein and made
25 part of this Agreement.
26 B. CONTRACTOR shall adhere to the COUNTY adopted Target Population
27 outlined in Exhibit A, "Scope of Work".
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I C. CONTRACTOR shall also perform all services and fulfill all responsibilities as
2 specified in COUNTY's Request for Proposal (RFP) No. 18-038 dated March 19, 2018, and
3 Addendum No. One (1) to COUNTY'S RFP No. 18-038 dated April 16, 2018, herein collectively
4 referred to as COUNTY's Revised RFP, and CONTRACTOR's Response to said Revised RFP dated
5 April 24, 2018, all incorporated herein by reference and made part of this Agreement. In the event of
6 any inconsistency among these documents, the inconsistency shall be resolved by giving precedence
7 in the following order of priority: 1) to this Agreement, including all Exhibits, 2) to the Revised RFP, 3)
8 to the Response to the Revised RFP. A copy of COUNTY's Revised RFP No. 18-038 and
9 CONTRACTOR's response thereto shall be retained and made available during the term of this
10 Agreement by COUNTY's DBH MHSA Administration.
11 D. CONTRACTOR is encouraged to engage in all quality improvement activities to
12 provide a welcoming environment, and to develop co-occurring substance use disorder and mental
13 health treatment capability for individuals and families as outlined in Exhibit B, "Full Service
14 Partnership Service Delivery Model", attached hereto and by this reference incorporated herein and
15 made part of this Agreement.
16 E. It is acknowledged by all parties hereto that COUNTY's DBH's Mental Health
17 Services Act (MHSA) Administrative unit shall monitor said MHSA TAY Mental Health Services and
18 Supports & Housing Services program in accordance with Section Fourteen (14) of this Agreement.
19 F. CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
20 consisting of staff from COUNTY's DBH's MHSA Administrative unit to discuss the MHSA TAY Mental
21 Health Services and Supports & Housing Services program, requirements, data reporting, training,
22 policies and procedures, overall program operations, outcomes, and any problems or foreseeable
23 problems that may arise.
24 G. It is acknowledged that upon execution of this Agreement, CONTRACTOR's
25 service sites shall be located at 2140 Merced Street, Suite 101, Fresno, California 93721 and 2934
26 Fresno Street, Fresno, California 93721. Any changes to the CONTRACTOR's location of the service
27 site may be made only upon thirty (30) days advanced written notification to COUNTY's DBH Director
28 and upon written approval from COUNTY's DBH Director, or designee.
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I H. CONTRACTOR shall maintain requirements as an organizational provider
2 throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement and
3 within Exhibit C, Wedi-Cal Organizational Provider Standards", attached hereto and incorporated
4 herein by reference and made part of this Agreement. If for any reason, this status is not maintained,
5 COUNTY may terminate this Agreement pursuant to Section Three (3) of this Agreement.
6 I. CONTRACTOR agrees that prior to providing services under the terms and
7 conditions of this Agreement, CONTRACTOR shall have appropriate staff hired and in place for
8 program services and operations or COUNTY may, in addition to other remedies it may have, suspend
9 referrals or terminate this Agreement, in accordance with Section Three (3) of this Agreement.
10 J. CONTRACTOR shall provide all behavioral health services, programs, and
11 practices with the vision, mission, and guiding principles of COUNTY's DBH as further described in
12 Exhibit D, "Fresno County Department of Behavioral Health Guiding Principles of Care Delivery,"
13 attached hereto and incorporated herein by reference.
14 2. TERM
15 This Agreement shall become effective upon execution and shall terminate on the 30tn
16 day of June, 2022. This term for the period of three (3) years and eight (8) months, which includes a
17 two (2) month ramp up period and six (6) month initial operational period, shall begin November 1,
18 2018 and terminate on June 30, 2019.
19 This Agreement may be extended for two (2) additional twelve (12) month periods upon
20 the written approval of both parties not later than sixty (60) days prior to the close of the then current
21 Agreement term. The COUNTY's DBH Director, or his or her designee, is authorized to execute such
22 written approval on behalf of COUNTY based on CONTRACTOR's satisfactory performance.
23 3. TERMINATION
24 A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
25 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
26 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
27 terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
28 B. Breach of Contract - COUNTY may immediately suspend or terminate this
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I Agreement in whole or in part, where in the determination of COUNTY there is:
2 1) An illegal or improper use of funds;
3 2) A failure to comply with any term of this Agreement;
4 3) A substantially incorrect or incomplete report submitted to COUNTY;
5 4) Improperly performed service.
6 In no event shall any payment by COUNTY constitute a waiver by COUNTY of
7 any breach of this Agreement or any default which may then exist on the part of CONTRACTOR.
8 Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
9 breach or default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment
10 to the COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the
11 judgment of COUNTY were not expended in accordance with the terms of this Agreement. The
12 CONTRACTOR shall promptly refund any such funds upon demand or at COUNTY's option, such
13 repayment shall be deducted from future payments owing to CONTRACTOR under this Agreement.
14 C. Without Cause - Under circumstances other than those set forth above, this
15 Agreement may be terminated by COUNTY upon the giving of sixty (60) days advance written notice
16 of an intention to terminate to CONTRACTOR.
17 4. COMPENSATION
18 COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
19 compensation in accordance with the budgets set forth in Exhibit E, attached hereto and by this
20 reference incorporated herein and made part of this Agreement.
21 A. Maximum Contract Amount
22 The maximum amount payable to CONTRACTOR for the period of effective upon
23 execution through June 30, 2019 shall not exceed One Million, Seven Hundred Seventy-Nine
24 Thousand, Eight Hundred Eighty-Eight and No/100 Dollars ($1,779,888.00).
25 The maximum amount payable to CONTRACTOR for the period of July 1, 2019
26 through June 30, 2020 shall not exceed Two Million, Six Hundred Seventy Thousand, Five Hundred
27 Forty-Eight and No/100 Dollars ($2,670,548.00).
28 The maximum amount payable to CONTRACTOR for the period of July 1, 2020
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I through June 30, 2021 shall not exceed Two Million, Seven Hundred Sixty-One Thousand, Four
2 Hundred Eight and No/100 Dollars ($2,761,408.00).
3 The maximum amount payable to CONTRACTOR for the period of July 1, 2021
4 through June 30, 2022 shall not exceed Two Million, Eight Hundred Forty-Three Thousand, Eight
5 Hundred Thirty-Two and No/100 Dollars ($2,843,832.00).
6 If this Agreement is extended for an additional twelve (12) month renewal period
7 beginning July 1, 2022 through June 30, 2023, the maximum amount payable to CONTRACTOR for
8 said period shall not exceed Two Million, Nine Hundred Twenty-Nine Thousand, Thirty-Six and No/100
9 Dollars ($2,929,036.00).
10 If this Agreement is extended for an additional twelve (12) month renewal period
11 beginning July 1, 2023 through June 30, 2024, the maximum amount payable to CONTRACTOR for
12 said period shall not exceed Three Million, Three Thousand, Seven Hundred Twenty-Seven and
13 No/100 Dollars ($3,003,727.00).
14 In no event shall the total maximum compensation amount under this Agreement
15 for the period beginning effective upon execution through June 30, 2022 exceed Ten Million, Fifty-Five
16 Thousand, Six Hundred Seventy-Six and No/100 Dollars ($10,055,676.00) for all CONTRACTOR(S)
17 combined.
18 If performance standards are met and this Agreement is extended for an
19 additional twelve (12) month term pursuant to Section 3, TERM, herein, then in no event shall the total
20 maximum compensation amount under this Agreement beginning effective upon execution through
21 June 30, 2023 exceed Twelve Million, Nine Hundred Eighty-Four Thousand, Seven Hundred Twelve
22 and No/100 Dollars ($12,984,712.00) for all CONTRACTOR(S) combined.
23 If performance standards are met and this Agreement is extended for an
24 additional twelve (12) month term pursuant to Section 3, TERM, herein, then in no event shall the total
25 maximum compensation amount under this Agreement beginning effective upon execution through
26 June 30, 2024 exceed Fifteen Million, Nine Hundred Eighty-Eight Thousand, Four Hundred Thirty-Nine
27 and No/100 Dollars ($15,988,439.00) for all CONTRACTOR(S) combined.
28 Payment shall be made upon certification or other proof satisfactory to
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I COUNTY's DBH that services have actually been performed by CONTRACTOR as specified in this
2 Agreement.
3 B. If CONTRACTOR fails to generate the Medi-Cal revenue and/or client fee
4 reimbursement amounts set forth in Exhibit E, the COUNTY shall not be obligated to pay the
5 difference between these estimated amounts and the actual amounts generated.
6 It is further understood by COUNTY and CONTRACTOR that any Medi-Cal
7 revenue and/or client fee reimbursements above the amounts stated herein will be used to directly
8 offset the COUNTY's contribution of COUNTY funds identified in Exhibit E. The offset of funds will
9 also be clearly identified in monthly invoices received from CONTRACTOR as further described in
10 Section Five (5) of this Agreement.
11 Travel shall be reimbursed based on actual expenditures and mileage
12 reimbursement shall be at CONTRACTOR's adopted rate per mile, not to exceed the Federal Internal
13 Revenue Services (IRS) published rate for the then current year.
14 C. It is understood that all expenses incidental to CONTRACTOR's performance of
15 services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply
16 with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
17 compensation.
18 D. Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
19 provided during the preceding month, within forty-five (45) days after the date of receipt and approval
20 by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be
21 made after receipt and verification of actual expenditures incurred by CONTRACTOR for monthly
22 program costs, as identified in Exhibit E, in the performance of this Agreement and shall be
23 documented to COUNTY on a monthly basis by the tenth (10th) of the month following the month of
24 said expenditures. The parties acknowledge that the CONTRACTOR will be performing hiring,
25 training, and credentialing of staff, and the COUNTY will be performing additional staff credentialing to
26 ensure compliance with State and Federal regulations.
27 E. COUNTY shall not be obligated to make any payments under this Agreement if
28 the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
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I terminated or expired.
2 All final invoices shall be submitted by CONTRACTOR within sixty (60) days
3 following the final month of service for which payment is claimed. No action shall be taken by
4 COUNTY on invoices submitted beyond the sixty (60) day closeout period. Any compensation which
5 is not expended by CONTRACTOR pursuant to the terms and conditions of this Agreement shall
6 automatically revert to COUNTY.
7 F. The services provided by CONTRACTOR under this Agreement are funded in
8 whole or in part by the State of California. In the event that funding for these services is delayed by
9 the State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred
10 payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The
11 period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller's
12 delay of payment to COUNTY plus forty-five (45) days.
13 G. CONTRACTOR shall be held financially liable for any and all future
14 disallowances/audit exceptions due to CONTRACTOR's deficiency discovered through the State audit
15 process and COUNTY utilization review during the course of this Agreement. At COUNTY's election,
16 the disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or shall
17 be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive
18 reimbursement for any units of services rendered that are disallowed or denied by the Fresno County
19 Mental Health Plan (Mental Health Plan) utilization review process or through the State Department of
20 Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients.
21 Notwithstanding the above, COUNTY must notify CONTRACTOR prior to any State audit process
22 and/or COUNTY utilization review. To the extent allowable by law, CONTRACTOR shall have the
23 right to be present during each phase of any State audit process and/or COUNTY utilization review
24 and shall be provided all documentation related to each phase of any State audit process and/or
25 COUNTY utilization review. Additionally, prior to any disallowances/audit exceptions becoming final,
26 CONTRACTOR shall be given at least ten (10) business days to respond to such proposed
27 disallowances/audit exceptions.
28 H. It is understood by CONTRACTOR and COUNTY that this Agreement is funded
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I with mental health funds to serve adult individuals with Severely Mentally III (SMI) disorders and
2 children/youth with Seriously Emotionally Disturbed (SED) disorders, many of whom have co-occurring
3 substance use disorders. It is further understood by CONTRACTOR and COUNTY that funds shall be
4 used to support appropriately integrated and documented treatment services for co-occurring mental
5 health and substance use disorders.
6 5. INVOICING
7 A. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each
8 month for the prior month's actual services rendered to DBH-Invoices@FresnoCountyCA.gov. After
9 CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for payment,
10 certify the expenditure, and submit electronic claiming data into COUNTY's electronic information system
11 for all clients, including those eligible for Medi-Cal as well as those that are not eligible for Medi-Cal,
12 including contracted cost per unit and actual cost per unit. COUNTY must pay CONTRACTOR before
13 submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible clients.
14 B. At the discretion of COUNTY's DBH Director, or his or her designee, if an invoice is
15 incorrect or is otherwise not in proper form or substance, COUNTY's DBH Director, or his or her designee,
16 shall have the right to withhold payment as to only that portion of the invoice that is incorrect or improper
17 after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services
18 for a period of ninety (90) days after notification of an incorrect or improper invoice. If after the ninety (90)
19 day period, the invoice(s) is still not corrected to COUNTY DBH's satisfaction, COUNTY's DBH Director, or
20 his or her designee, may elect to terminate this Agreement, pursuant to the termination provisions stated in
21 Section Three (3) of this Agreement. In addition, for invoices received ninety (90) days after the expiration
22 of each term of this Agreement or termination of this Agreement, at the discretion of COUNTY's DBH
23 Director, or his or her designee, COUNTY's DBH shall have the right to deny payment of any additional
24 invoices received.
25 C. Monthly invoices shall include a client roster, identifying volume reported by payer
26 group clients served (including third party payer of services) by month and year-to-date, including
27 percentages.
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I D. CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a
2 detailed general ledger(GL), itemizing costs incurred in the previous month. Failure to submit GL reports
3 and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until
4 there is compliance, as further described in Section Five (5) herein.
5 E. CONTRACTOR will remit annually within ninety (90) days from June 30, a schedule
6 to provide the required information on published charges for all authorized direct specialty mental health
7 services. The published charge listing will serve as a source document to determine the CONTRACTOR's
8 usual and customary charge prevalent in the public mental health sector that is used to bill the general
9 public, insurers or other non-Medi-Cal third party payers during the course of business operations.
10 F. CONTRACTOR shall submit monthly staffing reports that identify all direct service
11 and support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking
12 tool to determine if CONTRACTOR's program is staffed according to the services provided under this
13 Agreement.
14 G. CONTRACTOR must maintain financial records for a period of ten (10)years or
15 until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for
16 any disallowances related to inadequate documentation.
17 H. CONTRACTOR is responsible for collection and managing of data in a manner to
18 be determined by DHCS and the COUNTY's Mental Health Plan in accordance with applicable rules and
19 regulations. COUNTY's electronic information system is a critical source of information for purposes of
20 monitoring service volume and obtaining reimbursement.
21 I. CONTRACTOR shall submit service data into COUNTY's electronic information
22 system according to COUNTY's DBH documentation standards to allow the COUNTY to bill Medi-Cal, and
23 any other third-party source, for services and meet State and Federal reporting requirements.
24 J. CONTRACTOR must comply with all laws and regulations governing the Federal
25 Medicare program, including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C. section
26 1395 et seq; and 2)the regulations and rules promulgated by the Federal Centers for Medicare and
27 Medicaid Services as they relate to participation, coverage and claiming reimbursement. CONTRACTOR
28 will be responsible for compliance as of the effective date of each Federal, State or local law or regulation
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I specified.
2 K. If a client has dual coverage, such as other health coverage (OHC) or Federal
3 Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or
4 have validation of claiming with no response ninety (90) days after the claim was mailed before the service
5 can be entered into the COUNTY's electronic information system. CONTRACTOR must report all third
6 party collections for Medicare, third party or client pay or private pay in each monthly invoice and in the
7 annual cost report that is required to be submitted. A copy of explanation of benefits or CMS 1500 form is
8 required as documentation. CONTRACTOR must report all revenue collected from OHC, third-party,
9 client-pay or private-pay in each monthly invoice and in the cost report that is required to be submitted.
10 CONTRACTOR shall submit monthly invoices for reimbursement that equal the amount due
11 CONTRACTOR less any funding sources not eligible for Federal and State reimbursement.
12 CONTRACTOR must comply with all laws and regulations governing the Federal Medicare program,
13 including, but not limited to: 1)the requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2)
14 the regulation and rules promulgated by the Federal Centers for Medicare and Medicaid Services as they
15 relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for
16 compliance as of the effective date of each Federal, State or local law or regulation specified.
17 L. Data entry shall be the responsibility of the CONTRACTOR. COUNTY shall
18 monitor the volume of services and cost of services entered into the COUNTY's electronic information
19 system. Any and all audit exceptions resulting from the provision and reporting of specialty mental health
20 services by CONTRACTOR shall be the sole responsibility of the CONTRACTOR. CONTRACTOR will
21 comply with all applicable policies, procedures, directives and guidelines regarding the use of COUNTY's
22 electronic information system.
23 M. Medi-Cal Certification and Mental Health Plan Compliance
24 CONTRACTOR shall comply with any and all requests and directives associated
25 with COUNTY maintaining State Medi-Cal site certification. CONTRACTOR shall provide specialty mental
26 health services in accordance with the COUNTY's Mental Health Plan Compliance Program and Code of
27 Conduct and Ethics ("Code of Conduct"). CONTRACTOR must comply with the Code of Conduct as set
28 forth in Exhibit F, "Fresno County Mental Health Plan Compliance Program— Code of Coduct Policy and
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I Procedure", attached hereto and incorporated herein by reference and made part of this Agreement.
2 CONTRACTOR shall comply with any and all requests associated with any State/Federal reviews or
3 audits.
4 CONTRACTOR may provide direct specialty mental health services using pre-
5 licensed staff as long as the individual is approved as a provider by the COUNTY's Mental Health Plan, is
6 supervised by licensed staff, works within his/her scope and only delivers allowable direct specialty mental
7 health services. It is understood that each service is subject to audit for compliance with Federal and State
8 regulations, and that COUNTY may be making payments in advance of said review. In the event that a
9 service is disapproved, COUNTY may, at its sole discretion, withhold compensation or set off from other
10 payments due the amount of said disapproved services. CONTRACTOR shall be responsible for audit
11 exceptions to ineligible dates of services or incorrect application of utilization review requirements.
12 6. INDEPENDENT CONTRACTOR
13 In performance of the work, duties, and obligations assumed by CONTRACTOR under this
14 Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
15 CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
16 independent CONTRACTOR, and shall act in an independent capacity and not as an officer, agent,
17 servant, employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no
18 right to control or supervise or direct the manner or method by which CONTRACTOR shall perform its
19 work and function. However, COUNTY shall retain the right to administer this Agreement so as to verify
20 that CONTRACTOR is performing their obligations in accordance with the terms and conditions thereof.
21 CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules and
22 regulations, if any, of governmental authorities having jurisdiction over matters the subject thereof.
23 Because of its status as an independent contractor, CONTRACTOR shall have absolutely
24 no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
25 solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
26 benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
27 matters relating to payment of CONTRACTOR's employees, including compliance with Social Security,
28 withholding, and all other regulations governing such matters. It is acknowledged that during the term of
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I this Agreement, CONTRACTOR may be providing services to others unrelated to COUNTY or to this
2 Agreement.
3 7. MODIFICATION
4 Any matters of this Agreement may be modified from time to time by the written consent of
5 all the parties without, in any way, affecting the remainder.
6 Notwithstanding the above, changes to services, staffing, and responsibilities of the
7 CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health treatment, as
8 set forth in Exhibit A, may be made with the signed written approval of COUNTY's DBH Director, or his or
9 her designee, and CONTRACTOR through an amendment approved by COUNTY's County Counsel and
10 the COUNTY's Auditor-Controller's Office.
11 In addition, changes to expense category (i.e., Salary & Benefits, Facilities/Equipment,
12 Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, and
13 changes to the volume of units of services/types of service units to be provided as set forth in Exhibit E,
14 that do not exceed ten percent (10%) of the maximum compensation payable to the CONTRACTOR may
15 be made with the written approval of COUNTY's DBH Director, or his or her designee. Changes to the
16 expense categories in the budget that exceed ten percent (10%) of the maximum compensation payable
17 to the CONTRACTOR, may be made with the signed written approval of COUNTY's DBH Director, or his
18 or her designee through an amendment approved by COUNTY's Counsel and COUNTY's Auditor-
19 Controller's Office.
20 Said modifications shall not result in any change to the annual maximum
21 compensation amount payable to CONTRACTOR, as stated in this Agreement.
22 8. NON-ASSIGNMENT
23 No party shall assign, transfer or subcontract this Agreement nor their rights or duties under
24 this Agreement without the prior written consent of COUNTY.
25 9. HOLD-HARMLESS
26 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
27 defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
28 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY
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1 in connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents or
2 employees under this Agreement, and from any and all costs and expenses, including attorney fees
3 and court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
4 corporation who may be injured or damaged by the performance, or failure to perform, of
5 CONTRACTOR, their officers, agents or employees under this Agreement.
6 CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California audit
7 exceptions resulting from noncompliance herein on the part of CONTRACTOR.
8 10. INSURANCE
9 Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any third
10 parties, CONTRACTOR, at its sole expense, shall maintain in full force and affect the following insurance
11 policies throughout the term of this Agreement:
12 A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
13 Dollars ($2,000,000) per occurrence and an annual aggregate of Five Million
Dollars ($5,000,000). This policy shall be issued on a per occurrence basis.
14 COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire
15 legal liability or any other liability insurance deemed necessary because of the
16 nature of the Agreement.
17
B. Automobile Liability
18 Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto),
or if Consultant has no owned autos, Code 8 (hired) and 9 (n on-own ed).with
19 limits of not less than) One Million Dollars ($1,000,000) per accident for bodily
20 injury and property damage.
21
C. Real and Property Insurance
22 CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
23 loss payee. The personal property coverage shall be in an amount that will cover
the total of the COUNTY purchase and owned property, at a minimum, as
24 discussed in Section Twenty (21) of this Agreement.
25
26 All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of
27 the COUNTY'S personal property in possession of CONTRACTOR and/or used
28 in the execution of this Agreement. COUNTY will be identified on an appropriate
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certificate of insurance as the certificate holder and will be named as an
1 Additional Loss Payee on the Property Insurance Policy.
2 D. Professional Liability
Professional Liability Insurance with limits of not less than One Million Dollars
3 ($1,000,000) per occurrence, Three Million Dollars ($3,000,000) annual
aggregate. CONTRACTOR agrees that it shall maintain, at its sole expense, in
4 full force and effect for a period of three (3) years following the termination of this
Agreement, one or more policies of professional liability insurance with limits of
5 coverage as specified herein.
6
E. Child Abuse/Molestation and Social Services Coverage
7 CONTRACTOR shall have either separate policies or an umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
8 coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability. The policy
9 limits for these policies shall be One Million Dollars ($1,000,000) per occurrence
with a Two Million Dollars ($2,000,000) annual aggregate. The policies are to be
10 on a per occurrence basis.
11 F. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
12 California Labor Code.
13 G. Cyber Liability
14 Cyber Liability Insurance, with limits not less than $2,000,000 per occurrence or
claim, $2,000,000 aggregate. Coverage shall be sufficiently broad to respond to
15 duties and obligations undertaken by CONTRACTOR in this agreement and shall
include, but not be limited to, claims involving infringement of intellectual
16 property, including but not limited to infringement of copyright, trademark, trade
dress, invasion of privacy violations, information theft, damage to or destruction
17 of electronic information, release of private information, alteration of electronic
information, extortion and network security. The policy shall provide coverage for
18 breach response costs as well as regulatory fines and penalties as well as credit
19 monitoring expenses with limits sufficient to respond to these obligations.
20 H. Waiver of Subrogation
CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogation
21 which any insurer of said CONTRACTOR may acquire against the COUNTY by
virtue of the payment of any loss under insurance. CONTRACTOR agrees to
22 obtain any endorsement that may be necessary to affect this waiver of
subrogation, but this provision applies regardless of whether or not the COUNTY
23 has received a waiver of subrogation endorsement from the insurer.
24
25 CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
26 naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
27 additional insured, but only insofar as the operations under this Agreement are concerned. Such coverage
28 for additional insured shall apply as primary insurance and any other insurance, or self-insurance,
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I maintained by COUNTY, its officers, agents and employees shall be excess only and not contributing with
2 insurance provided under CONTRACTOR's policies herein. This insurance shall not be cancelled or
3 changed without a minimum of thirty (30) days advance written notice given to COUNTY.
4 Within thirty (30) days from the date CONTRACTOR signs this Agreement,
5 CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
6 foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 3133 N.
7 Millbrook Ave, Fresno, California, 93703, Attention: Mental Health Contracted Services Division, stating
8 that such insurance coverages have been obtained and are in full force; that the County of Fresno, its
9 officers, agents and employees will not be responsible for any premiums on the policies; that such
10 Commercial General Liability insurance names the County of Fresno, its officers, agents and employees,
11 individually and collectively, as additional insured, but only insofar as the operations under this Agreement
12 are concerned; that such coverage for additional insured shall apply as primary insurance and any other
13 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, shall be excess
14 only and not contributing with insurance provided under CONTRACTOR's policies herein; and that this
15 insurance shall not be cancelled or changed without a minimum of thirty (30) days advance, written notice
16 given to COUNTY.
17 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
18 provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement
19 upon the occurrence of such event.
20 All policies shall be with admitted insurers licensed to do business in the State of California.
21 Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of A FSC VII or
22 better.
23 11. LICENSES/CERTIFICATES
24 Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR's staff shall
25 maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for the
26 provision of the services hereunder and required by the laws and regulations of the United States of
27 America, State of California, the County of Fresno, and any other applicable governmental agencies.
28 CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such
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I licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of any
2 appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR's staff shall comply with all
3 applicable laws, rules or regulations, as may now exist or be hereafter changed.
4 12. RECORDS
5 CONTRACTOR shall maintain records in accordance with Exhibit G, "Documentation
6 Standards for Client Records", attached hereto and by this reference incorporated herein and made part of
7 this Agreement. COUNTY shall be allowed to review all records of services provided, including the goals
8 and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
9 All medical records shall be maintained for a minimum of ten (10) years from the date of the end of the
10 Agreement.
11 13. REPORTS
12 A. Outcome Reports
13 CONTRACTOR shall submit to COUNTY's DBH service outcome reports as
14 reasonably requested by COUNTY's DBH. Outcome reports and performance outcome measures
15 requirements are subject to change at COUNTY's DBH discretion. All performance outcome measures
16 shall adhere to the Commission on Accreditation of Rehabilitation Facilities (CARF) standards as identified
17 in Exhibit H, attached hereto and incorporated herein by reference and made part of this Agreement.
18 B. Additional Reports
19 CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
20 data, and other information as COUNTY's DBH may reasonably request pertaining to matters covered by
21 this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
22 required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments until
23 there is compliance. In addition, CONTRACTOR shall provide written notification and explanation to
24 COUNTY within five (5) days of any funds received from another source to conduct the same services
25 covered by this Agreement.
26 C. Cost Report
27 CONTRACTOR agrees to submit a complete and accurate detailed cost report
28 on an annual basis for each fiscal year ending June 30t" in the format prescribed by the DHCS for the
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I purposes of Short Doyle Medi-Cal reimbursements and total costs for programs. The cost report will
2 be the source document for several phases of settlement with the DHCS for the purposes of Short
3 Doyle Medi-Cal reimbursement. CONTRACTOR shall report costs under their approved legal entity
4 number established during the Medi-Cal certification process. The information provided applies to
5 CONTRACTOR for program related costs for services rendered to Medi-Cal and non-Medi-Cal.
6 CONTRACTOR will remit a schedule to provide the required information on published charges (PC)
7 for all authorized services. The report will serve as a source document to determine their usual and
8 customary charge prevalent in the public mental health sector that is used to bill the general public,
9 insurers, or other non-Medi-Cal third party payers during the course of business operations.
10 CONTRACTOR must report all collections for Medi-Cal/Medicare services and collections. The
11 CONTRACTOR shall also submit with the cost report a copy of the CONTRACTOR's general ledger
12 that supports revenues and expenditures and reconciled detailed report of reported total units of
13 services rendered under this Agreement to the units of services reported by CONTRACTOR to
14 COUNTY'S data system.
15 Cost Reports must be submitted to the COUNTY as a hard copy with a signed
16 cover letter and electronic copy of completed DHCS cost report form along with requested support
17 documents following each fiscal year ending June 30th. During the month of September of each year
18 this Agreement is effective, COUNTY will issue instructions of the annual cost report which indicates
19 the training session, DHCS cost report template worksheets, and deadlines to submit, as determined
20 by State annually. CONTRACTOR(S) shall remit a hard copy of cost report to County of Fresno,
21 Attention: Cost Report Team, PO BOX 45003, Fresno CA 93718. CONTRACTOR(S) shall remit the
22 electronic copy or any inquiries to DBHcostreportteam(a-)_FresnoCountyCA.gov.
23 All Cost Reports must be prepared in accordance with General Accepted
24 Accounting Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3)
25 and 5718(c). Unallowable costs such as lobby or political donations must be deducted on the cost
26 report and invoice reimbursement
27 If the CONTRACTOR does not submit the cost report by the deadline, including
28 any extension period granted by the COUNTY, the COUNTY may withhold payments of pending
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I invoicing under compensation until the cost report has been submitted and clears COUNTY desk audit
2 for completeness.
3 D. Settlements with State Department of Health Care Services (DHCS)
4 During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
5 agree to settle dollar amounts disallowed or settled in accordance with DHCS audit settlement findings
6 related to the reimbursement provided under this Agreement. CONTRACTOR will participate in the
7 several phases of settlements between COUNTY/CONTRACTOR and DHCS. The phases of initial cost
8 reporting for settlement according to State reconciliation of records for paid Medi-Cal services and audit
9 settlement are: State DHCS audit 1) initial cost reporting - after an internal review by COUNTY, the
10 COUNTY files the cost report with State DHCS on behalf of the CONTRACTOR's legal entity for the fiscal
11 year; 2) Settlement—State reconciliation of records for paid Medi-Cal services, approximately 18 to 36
12 months following the State close of the fiscal year, DHCS will send notice for any settlement under this
13 provision to the COUNTY; 3)Audit Settlement-State DHCS audit. After final reconciliation and settlement
14 DHCS may conduct a review of medical records, cost report along with support documents submitted to
15 COUNTY in initial submission to determine accuracy and may disallow costs and/or units of services.
16 COUNTY may choose to appeal and therefore reserves the right to defer payback settlement with
17 CONTRACTOR until resolution of the appeal. DHCS Audits will follow Federal Medicaid procedures for
18 managing overpayments. If at the end of the Audit Settlement, the COUNTY determines that it overpaid
19 the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related overpayment back to
20 the COUNTY.
21 Funds owed to COUNTY will be due within forty-five (45) days of notification by the
22 COUNTY, or COUNTY shall withhold future payments until all excess funds have been recouped by
23 means of an offset against any payments then or thereafter owing to COUNTY under this or any other
24 Agreement between the COUNTY and CONTRACTOR.
25 14. MONITORING
26 CONTRACTOR agrees to extend to COUNTY's staff, COUNTY's DBH Director and the
27 State DHCS, or their designees, the right to review and monitor records, services or procedures, at any
28 time, in regard to clients, as well as the overall operation of CONTRACTOR's performance, in order to
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I ensure compliance with the terms and conditions of this Agreement.
2 15. REFERENCES TO LAWS AND RULES
3 In the event any law, regulation, or policy referred to in this Agreement is amended during
4 the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of
5 such amendment.
6 16. COMPLIANCE WITH STATE REQUIREMENTS
7 CONTRACTOR recognizes that COUNTY operates its mental health programs under an
8 agreement with the State DHCS, and that under said agreement the State imposes certain requirements
9 on COUNTY and its subcontractors. CONTRACTOR shall adhere to all State requirements, including
10 those identified in Exhibit I, "State Mental Health Requirements", attached hereto and by this reference
11 incorporated herein and made part of this Agreement. CONTRACTOR shall also file an incident report for
12 all incidents involving clients, following the COUNTY's DBH's "Incident Reporting and Intensive Analysis"
13 policy and procedure guide and using the "Incident Report" Worksheet identified in Exhibit J, "Fresno
14 County Mental Health Plan Incident Reporting", attached hereto and by this reference incorporated herein
15 and made part of this Agreement, or a protocol and worksheet presented by CONTRACTOR that is
16 accepted by COUNTY's DBH Director, or his or her designee.
17 17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
18 CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health
19 Plan Grievances and Appeals Process, as described in Exhibit K, "Fresno County Mental Health Plan —
2 0 Grievances", attached hereto and by this reference incorporated herein and made part of this Agreement.
21 18. CONFIDENTIALITY
22 All services performed by CONTRACTOR under this Agreement shall be in strict
23 conformance with all applicable Federal, State of California and/or local laws and regulations relating to
24 confidentiality.
25 19. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
26 COUNTY and CONTRACTOR each consider and represent themselves as covered
27 entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
28 191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
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I COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
2 only for treatment, payment, and health care operations.
3 COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
4 PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
5 Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder
6 by the U.S. Department of Health and Human Services (HIPAA Regulations) and other applicable laws.
7 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
8 CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as
9 set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504€of the Code of
10 Federal Regulations.
11 20. DATA SECURITY
12 For the purpose of preventing the potential loss, misappropriation or inadvertent access,
13 viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
14 COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into
15 a contractual relationship with the COUNTY for the purpose of providing services under this Agreement
16 must employ adequate data security measures to protect the confidential information provided to
17 CONTRACTOR by the COUNTY, including but not limited to the following:
18 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
19 CONTRACTOR may not connect to COUNTY networks via personally-owned
20 mobile, wireless or handheld devices, unless the following conditions are met:
21 1) CONTRACTOR has received authorization by COUNTY for telecommuting
22 purposes;
23 2) Current virus protection software is in place;
24 3) Mobile device has the remote wipe feature enabled; and
25 4) A secure connection is used.
26 B. CONTRACTOR-Owned Computers or Computer Peripherals
27 CONTRACTOR may not bring CONTRACTOR-owned computers or computer
28 peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief Information
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I Officer, and/or his or her designee(s), including but not limited to mobile storage devices. If data is
2 approved to be transferred, data must be stored on a secure server approved by the COUNTY and
3 transferred by means of a Virtual Private Network (VPN) connection, or another type of secure connection.
4 Said data must be encrypted.
5 C. COUNTY-Owned Computer Equipment
6 CONTRACTOR may not use COUNTY computers or computer peripherals on non-
7 COUNTY premises without prior authorization from the COUNTY's Chief Information Officer, and/or his or
8 her designee(s).
9 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive data on
10 any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
11 E. CONTRACTOR shall be responsible to employ strict controls to ensure the integrity
12 and security of COUNTY's confidential information and to prevent unauthorized access, viewing, use or
13 disclosure of data maintained in computer files, program documentation, data processing systems, data
14 files and data processing equipment which stores or processes COUNTY data internally and externally.
15 F. Confidential client information transmitted to one party by the other by means of
16 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
17 BIT or higher. Additionally, a password or pass phrase must be utilized.
18 G. CONTRACTOR is responsible to immediately notify COUNTY of any violations,
19 breaches or potential breaches of security related to COUNTY's confidential information, data maintained
20 in computer files, program documentation, data processing systems, data files and data processing
21 equipment which stores or processes COUNTY data internally or externally.
22 H. COUNTY shall provide oversight to CONTRACTOR's response to all incidents
23 arising from a possible breach of security related to COUNTY's confidential client information provided to
24 CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as
25 required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be
26 responsible for all costs incurred as a result of providing the required notification.
27 21. PROPERTY OF COUNTY
28 A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
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1 intangible property obtained or controlled under COUNTY's Mental Health Plan for use in operational
2 capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items will
3 be on a straight-line basis.
4 For COUNTY purposes, fixed assets must fulfill three qualifications:
5 1. Asset must have life span of over one year.
6 2. The asset is not a repair part
7 3. The asset must be valued at or greater than the capitalization thresholds for
8 the asset type
9
10 Asset type Threshold
• land $0
11 buildings and improvements $100,000
• infrastructure $100,000
12 be tangible $5,000
0 equipment
13 0 vehicles
• or intangible asset $100,000
14 0 Internally generated software
0 Purchased software
15 0 Easements
0 Patents
16 and capital lease $5,000
17
18 Qualified fixed asset equipment is to be reported and approved by
19 COUNTY. If it is approved and identified as an asset it will be tagged with a COUNTY program number. A
20 Fixed Asset Log, as shown in Exhibit L, attached hereto and incorporated herein by reference and made
21 part of this Agreement, will be maintained by COUNTY's Asset Management System and annual
22 inventoried until the asset is fully depreciated. During the terms of this Agreement, CONTRACTOR's fixed
23 assets may be inventoried in comparison to COUNTY's DBH Asset Inventory System.
24 B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
25 more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are sensitive
26 assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and other sensitive
27 items as determined by COUNTY's DBH Director, or his or her designee. CONTRACTOR maintains a
28 tracking system on the items and are not required to be capitalize or depreciated. The items are subject to
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I annual inventory for compliance.
2 C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
3 Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in an
4 annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of this
5 Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are returned to
6 COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY-owned
7 undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
8 assets at the expiration or termination of this Agreement.
9 CONTRACTOR further agrees to the following:
10 1. To maintain all items of equipment in good working order and condition,
11 normal wear and tear is expected;
12 2. To label all items of equipment with COUNTY assigned program number, to
13 perform periodic inventories as required by COUNTY and to maintain an inventory list showing where and
14 how the equipment is being used, in accordance with procedures developed by COUNTY. All such lists
15 shall be submitted to COUNTY within ten (10) days of any request therefore; and
16 3. To report in writing to COUNTY immediately after discovery, the lost or theft
17 of any items of equipment. For stolen items, the local law enforcement agency must be contacted and a
18 copy of the police report submitted to COUNTY.
19 D. The purchase of any equipment by CONTRACTOR with funds provided hereunder
20 shall require the prior written approval of COUNTY's DBH, shall fulfill the provisions of this Agreement as
21 appropriate, and must be directly related to CONTRACTOR's services or activity under the terms of this
22 Agreement. COUNTY's DBH may refuse reimbursement for any costs resulting from equipment
23 purchased, which are incurred by CONTRACTOR, if prior written approval has not been obtained from
24 COUNTY.
25 E. CONTRACTOR must obtain prior written approval from COUNTY's DBH whenever
26 there is any modification or change in the use of any property acquired or improved, in whole or in part,
27 using funds under this Agreement. If any real or personal property acquired or improved with said funds
28 identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
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1 Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value
2 of the property, less any portion thereof attributable to expenditures of funds not provided under this
3 Agreement. These requirements shall continue in effect for the life of the property. In the event this
4 Agreement expires, or terminates, the requirements for this Section shall remain in effect for activities or
5 property funded with said funds, unless action is taken by the State government to relieve COUNTY of
6 these obligations.
7 22. NON-DISCRIMINATION
8 During the performance of this Agreement, CONTRACTOR and its subcontractors shall
9 not deny the contract's benefits to any person on the basis of race, religious creed, color, national
10 origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital
11 status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and
12 veteran status, nor shall they discriminate unlawfully against any employee or applicant for
13 employment because of race, religious creed, color, national origin, ancestry, physical disability,
14 mental disability, medical condition, genetic information, marital status, sex, gender, gender identity,
15 gender expression, age, sexual orientation, or military or veteran status.
16 CONTRACTOR shall ensure that the evaluation and treatment of employees and
17 applicants for employment are free of such discrimination. CONTRACTOR and subcontractors shall
18 comply with the provisions of the Fair Employment and Housing Act (Gov. Code §12800 et seq.), the
19 regulations promulgated thereunder (Cal. Code Regs., tit. 2, §11000 et seq.), the provisions of Article
20 9.5, Chapter 1, Part 1, Division 3, Title 2 of the Government Code (Gov. Code §11135-11139.5), and
21 the regulations or standards adopted by the awarding state agency to implement such article.
22 CONTRACTOR shall permit access by representatives of the Department of Fair Employment and
23 Housing and the awarding state agency upon reasonable notice at any time during the normal
24 business hours, but in no case less than twenty-four (24) hours' notice, to such of its books, records,
25 accounts, and all other sources of information and its facilities as said Department or Agency shall
26 require to ascertain compliance with this clause. CONTRACTOR and its subcontractors shall give
27 written notice of their obligations under this clause to labor organizations with which they have a
28 collective bargaining or other agreement. (See Cal. Code Regs., tit. 2, §11105) CONTRACTOR(S)
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I shall include the Non-Discrimination and compliance provisions of this clause in all subcontracts to
2 perform work under this Agreement.
3
4 23. CULTURAL COMPETENCY
5 As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
6 A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45 C.F.R. Part
7 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance from
8 discriminating against persons based on race, color, national origin, sex, disability or religion. This is
9 interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
10 participation in federally funded programs through the provision of comprehensive and quality bilingual
11 services.
12 B. Policies and procedures for ensuring access and appropriate use of trained
13 interpreters and material translation services for all LEP clients, including, but not limited to, assessing the
14 cultural and linguistic needs of its clients, training of staff on the policies and procedures, and monitoring its
15 language assistance program. The CONTRACTOR's procedures must include ensuring compliance of any
16 sub-contracted providers with these requirements.
17 C. CONTRACTOR shall not use minors as interpreters.
18 D. CONTRACTOR shall provide and pay for interpreting and translation services to
19 persons participating in CONTRACTOR's services who have limited or no English language proficiency,
20 including services to persons who are deaf or blind. Interpreter and translation services shall be provided
21 as necessary to allow such participants meaningful access to the programs, services and benefits provided
22 by CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR's "vital
23 documents" (those documents that contain information that is critical for accessing CONTRACTOR's
24 services or are required by law) shall be provided to participants at no cost to the participant.
25 CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or
26 translate for a program participant, or who directly communicate with a program participant in a language
27 other than English, demonstrate proficiency in the participant's language and can effectively communicate
28 any specialized terms and concepts peculiar to CONTRACTOR's services.
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I E. In compliance with the State mandated Culturally and Linguistically Appropriate
2 standards as published by the Office of Minority Health, CONTRACTOR must submit to COUNTY for
3 approval, within sixty (60) days from date of contract execution, CONTRACTOR's plan to address all
4 fifteen (15) national cultural competency standards as set forth in the Exhibit M, "National Standards for
5 Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care", attached hereto and
6 by this reference incorporated herein and made part of this Agreement. COUNTY's annual on-site
7 review of CONTRACTOR shall include collection of documentation to ensure all national standards are
8 implemented. As the national competency standards are updated, CONTRACTOR's plan must be
9 updated accordingly. Cultural competency training for CONTRACTOR's staff should be substantively
10 integrated into health professions education and training at all levels, both academic and functional,
11 including core curriculum, professional Iicensure, and continuing professional development programs.
12 CONTRACTOR on a monthly basis shall provide COUNTY DBH a monthly monitoring tool/report that
13 shows all CONTRACTOR's staff cultural competency trainings completed.
14 24. AMERICANS WITH DISABILITIES ACT
15 CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to
16 this Agreement shall comply with the accessibility requirements of Section 508 of the Rehabilitation Act
17 and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. § 794 (d)), and regulations
18 implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998,
19 Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic and
20 information technology (EIT) accessible to people with disabilities. California Government Code section
21 11135 codifies section 508 of the Act requiring accessibility of electronic and information technology.
22 25. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
23 To the extent necessary to prevent disallowance of reimbursement under section
24 1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four(4)
25 years after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon
26 written request to the Secretary of the United States Department of Health and Human Services, or upon
27 request to the Comptroller General of the United States General Accounting Office, or any of their duly
28 authorized representatives, a copy of this Agreement and such books, documents, and records as are
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Fresno, CA
I necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR under
2 this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any of its
3 duties under this Agreement through a subcontract, with a value or cost of Ten Thousand and No/100
4 Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such Agreement
5 shall contain a clause to the effect that until the expiration of four(4) years after the furnishing of such
6 services pursuant to such subcontract, the related organizations shall make available, upon written request
7 to the Secretary of the United States Department of Health and Human Services, or upon request to the
8 Comptroller General of the United States General Accounting Office, or any of their duly authorized
9 representatives, a copy of such subcontract and such books, documents, and records of such organization
10 as are necessary to verify the nature and extent of such costs.
11 26. SINGLE AUDIT CLAUSE
12 A. If CONTRACTOR expends Seven Hundred Fifty Thousand and No/100 Dollars
13 ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an
14 annual audit in accordance with the requirements of the Single Audit Standards as set forth in Office of
15 Management and Budget (OMB) Circular 2 CFR 200. CONTRACTOR shall submit said audit and
16 management letter to COUNTY. The audit must include a statement of findings or a statement that there
17 were no findings. If there were negative findings, CONTRACTOR must include a corrective action plan
18 signed by an authorized individual. CONTRACTOR agrees to take action to correct any material non-
19 compliance or weakness found as a result of such audit. Such audit shall be delivered to COUNTY's DBH
20 Business Office, for review within nine (9) months of the end of any fiscal year in which funds were
21 expended and/or received for the program. Failure to perform the requisite audit functions as required by
22 this Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY's option,
23 contracting with a public accountant to perform said audit, or, may result in the inability of COUNTY to
24 enter into future agreements with CONTRACTOR. All audit costs related to this Agreement are the sole
25 responsibility of CONTRACTOR.
26 B. A single audit report is not applicable if CONTRACTOR's Federal contracts do not
27 exceed the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or
28 CONTRACTOR's only funding is through Drug-related Medi-Cal. If a single audit is not applicable, a
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I program audit must be performed and a program audit report with management letter shall be submitted
2 by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR's solvency. Said
3 audit report shall be delivered to COUNTY's DBH Business Office, for review no later than nine (9) months
4 after the close of the fiscal year in which the funds supplied through this Agreement are expended. Failure
5 to comply with this Act may result in COUNTY performing the necessary audit tasks or contracting with a
6 qualified accountant to perform said audit. All audit costs related to this Agreement are the sole
7 responsibility of CONTRACTOR who agrees to take corrective action to eliminate any material
8 noncompliance or weakness found as a result of such audit. Audit work performed by COUNTY under this
9 paragraph shall be billed to the CONTRACTOR at COUNTY cost, as determined by COUNTY's Auditor-
10 Controller/Treasurer-Tax Collector.
11 C. CONTRACTOR shall make available all records and accounts for inspection by
12 COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal
13 Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
14 least three (3) years following final payment under this Agreement or the closure of all other pending
15 matters, whichever is later.
16 27. COMPLIANCE
17 CONTRACTOR agrees to comply with the COUNTY's Code of Conduct in accordance with
18 Exhibit F. Within thirty (30) days of entering into this Agreement with the COUNTY, CONTRACTOR shall
19 have all of CONTRACTOR's employees, agents and subcontractors providing services under this
20 Agreement certify in writing, that he or she has received, read, understood, and shall abide by the
21 COUNTY's Code of Conduct. CONTRACTOR shall ensure that within thirty (30) days of hire, all new
22 employees, agents and subcontractors providing services under this Agreement shall certify in writing that
23 he or she has received, read, understood, and shall abide by the Contractor Code of Conduct .
24 CONTRACTOR understands that the promotion of and adherence to the Code of Conduct is an element in
25 evaluating the performance of CONTRACTOR and its employees, agents and subcontractors.
26 Within thirty (30) days of entering into this Agreement, and annually thereafter, all
27 employees, agents and subcontractors providing services under this Agreement shall complete general
28 compliance training and appropriate employees, agents and subcontractors shall complete documentation
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I and billing or billing/reimbursement training. All new employees, agents and subcontractors shall attend
2 the appropriate training within thirty (30) days of hire. Each individual who is required to attend training
3 shall certify in writing that he or she has received the required training. The certification shall specify the
4 type of training received and the date received. The certification shall be provided to the COUNTY's
5 Compliance Officer at 3133 N. Millbrook, Fresno, California 93703. CONTRACTOR agrees to reimburse
6 COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result
7 of CONTRACTOR's violation of the terms of this Agreement.
8 28. ASSURANCES
9 In entering into this Agreement, CONTRACTOR certifies that neither it, nor any of its
10 officers, are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
11 Health Care Programs; that neither it, nor any of its officers, have been convicted of a criminal offense
12 related to the provision of health care items or services; nor has it, or any of its officers, been reinstated to
13 participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or
14 ineligibility. If COUNTY learns, subsequent to entering into a contract, that CONTRACTOR is ineligible on
15 these grounds, COUNTY will remove CONTRACTOR from responsibility for, or involvement with,
16 COUNTY's business operations related to the Federal Health Care Programs and shall remove such
17 CONTRACTOR from any position in which CONTRACTOR's compensation, or the items or services
18 rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by
19 Federal Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR
20 is reinstated into participation in the Federal Health Care Programs.
21 A. If COUNTY has notice that either CONTRACTOR, or its officers, has been charged
22 with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during the
23 term of any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the
24 accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
25 circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of the
26 charges or the proposed exclusion.
27 B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
28 subcontractors of CONTRACTOR who, in each case, are expected to perform professional services under
- 29 - COUNTY OF FRESNO
Fresno, CA
I this Agreement, will be queried as to whether(1)they are now or ever have been excluded, suspended,
2 debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they have been
3 convicted of a criminal offense related to the provision of health care items or services; and or(3)they
4 have been reinstated to participate in the Federal Health Care Programs after a period of exclusion,
5 suspension, debarment, or ineligibility.
6 1. In the event the potential employee or subcontractor informs
7 CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
8 convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
9 or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
10 subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
11 2. Notwithstanding the above, COUNTY at its discretion may terminate this
12 Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
13 defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
14 CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
15 Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
16 to protect the interests of COUNTY consumers.
17 C. CONTRACTOR shall verify (by asking the applicable employees and
18 subcontractors)that all current employees and existing subcontractors who, in each case, are expected to
19 perform professional services under this Agreement (1) are not currently excluded, suspended, debarred,
20 or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted of a
21 criminal offense related to the provision of health care items or services; and (3) have not been reinstated
22 to participate in the Federal Health Care Program after a period of exclusion, suspension, debarment, or
23 ineligibility. In the event any existing employee or subcontractor informs CONTRACTOR that he or she is
24 excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs,
25 or has been convicted of a criminal offense relating to the provision of health care services,
26 CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
27 relating to services provided to COUNTY.
28 1. CONTRACTOR agrees to notify COUNTY immediately during the term of
- 30 - COUNTY OF FRESNO
Fresno, CA
1 this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is
2 providing professional services under this Agreement is excluded, suspended, debarred or otherwise
3 ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
4 to the provision of health care services.
5 2. Notwithstanding the above, COUNTY at its discretion may terminate this
6 Agreement in accordance with Section 3 of this Agreement, or require adequate assurance (as defined by
7 COUNTY)that no excluded, suspended or otherwise ineligible employee or subcontractor of
8 CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
9 Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
10 to protect the interests of COUNTY consumers.
11 D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
12 information from COUNTY which may be necessary to complete any internal or external audits relating to
13 CONTRACTOR's compliance with the provisions of this Section.
14 E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
15 imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of
16 CONTRACTOR's obligations as described in this Section.
17 29. PUBLICITY PROHIBITION
18 None of the funds, materials, property or services provided directly or indirectly under this
19 Agreement shall be used for CONTRACTOR's advertising, fundraising, or publicity (i.e., purchasing of
20 tickets/tables, silent auction donations, etc.)for the purpose of self-promotion. Notwithstanding the above,
21 publicity of the services described in Section One (1) of this Agreement shall be allowed as necessary to
22 raise public awareness about the availability of such specific services when approved in advance by
23 COUNTY's DBH Director or his or her designee and at a cost to be provided in Exhibit E for such items as
24 written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related
25 expense(s).
26 30. COMPLAINTS
27 CONTRACTOR shall log complaints and the disposition of all complaints from a client or a
28 client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
- 31 - COUNTY OF FRESNO
Fresno, CA
I COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (101h) day of the following month,
2 in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and attach
3 documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of their
4 right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to
5 State licensing bodies that affect COUNTY clients within twenty-four(24) hours of receipt of a complaint.
6 Within ten (10) days after each incident or complaint affecting COUNTY clients,
7 CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
8 the complaint, the complaint and CONTRACTOR's disposition of, or corrective action taken to resolve the
9 complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit K.
10 CONTRACTOR shall file an incident report for all incidents involving clients, following the protocol and
11 using the worksheet identified in Exhibit J and incorporated herein by reference and made part of this
12 Agreement.
13 31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
14 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
15 managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 §455.101 455.104, and
16 455.106(a)(1),(2).
17 In accordance with C.F.R., Title 42 §§455.101, 455.104, 455.105 and 455.106(a)(1),(2),
18 the following information must be disclosed by CONTRACTOR by completing Exhibit N, "Disclosure of
19 Ownership and Control Interest Statement", attached hereto and by this reference incorporated herein and
20 made part of this Agreement. CONTRACTOR shall submit this form to the COUNTY's DBH within thirty
21 (30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any changes to
22 this information within thirty-five (35) days of occurrence by completing Exhibit N, "Disclosure of Ownership
23 and Control Interest Statement." Submissions shall be scanned pdf copies and are to be sent via email to
24 the assigned Mental Health Contracted Services Staff Analyst.
25 32. DISCLOSURE—CRIMINAL HISTORY AND CIVIL ACTIONS
26 CONTRACTOR is required to disclose if any of the following conditions apply to them, their
27 owners, officers, corporate managers and partners (hereinafter collectively referred to as
28 "CONTRACTOR"):
- 32 - COUNTY OF FRESNO
Fresno, CA
I A. Within the three-year period preceding the Agreement award, they have been
2 convicted of, or had a civil judgment rendered against them for:
3 1. Fraud or a criminal offense in connection with obtaining, attempting to
4 obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction;
5 2. Violation of a federal or state antitrust statute;
6 3. Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
7 or
8 4. False statements or receipt of stolen property.
9 B. Within a three-year period preceding their Agreement award, they have had a
10 public transaction (federal, state, or local)terminated for cause or default.
11 Disclosure of the above information will not automatically eliminate CONTRACTOR from
12 further business consideration. The information will be considered as part of the determination of whether
13 to continue and/or renew this Agreement and any additional information or explanation that a
14 CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
15 that the CONTRACTOR failed to disclose required information, any contract awarded to such
16 CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms
17 and conditions of the award.
18 CONTRACTOR must sign a "Certification Regarding Debarment, Suspension, and Other
19 Responsibility Matters - Primary Covered Transactions" in the form set forth in Exhibit O, attached hereto
20 and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
21 must immediately advise the COUNTY's DBH in writing if, during the term of this Agreement: (1)
22 CONTRACTOR becomes suspended, debarred, excluded or ineligible for participation in federal or state
23 funded programs or from receiving federal funds as listed in the excluded parties' list system
24 (http://www.epls.gov); or(2) any of the above listed conditions become applicable to CONTRACTOR.
25 CONTRACTOR shall indemnify, defend and hold the COUNTY harmless for any loss or damage resulting
26 from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification
27 Regarding Debarment, Suspension, and Other Responsibility Matters.
28 ///
- 33 - COUNTY OF FRESNO
Fresno, CA
1 33. DISCLOSURE OF SELF-DEALING TRANSACTIONS
2 This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-
a profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR changes its
4 status to operate as a corporation.
5 Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing
6 transactions that they are a party to while CONTRACTOR is providing goods or performing services under
7 this Agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR is a party
8 and in which one or more of its directors has a material financial interest. Members of the Board of
9 Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a,
10 "Self-Dealing Transaction Disclosure Form", attached hereto as Exhibit P and incorporated herein by
11 reference and made part of this Agreement, and submitting it to the COUNTY prior to commencing with
12 the self-dealing transaction or immediately thereafter.
13 34. AUDITS AND INSPECTIONS
14 The CONTRACTOR shall at any time during business hours, and as often as the COUNTY
15 may deem necessary, make available to the COUNTY for examination all of its records and data with
16 respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the
17 COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to ensure
18 CONTRACTOR's compliance with the terms of this Agreement.
19 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
20 CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period of
21 three (3)years after final payment under contract (California Government Code section 8546.7).
22 35. NOTICES
23 The persons having authority to give and receive notices under this Agreement and their
24 addresses include the following:
COUNTY CONTRACTOR
25
Director, Fresno County Chief Executive Officer
26 Department of Behavioral Health Turning Point of Central California
3133 N. Millbrook Ave P.O. Box 7447
27 Fresno, CA 93702 Visalia, CA 93290-7447
28 All notices between the COUNTY and CONTRACTOR provided for or permitted under this
- 34 - COUNTY OF FRESNO
Fresno, CA
1 Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
2 an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
3 personal service is effective upon service to the recipient. A notice delivered by first-class United States
4 mail is effective three COUNTY business days after deposit in the United States mail, postage prepaid,
5 addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
6 COUNTY business day after deposit with the overnight commercial courier service, delivery fees prepaid,
7 with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by
8 telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission
9 is completed outside of COUNTY business hours, then such delivery shall be deemed to be effective at
10 the next beginning of a COUNTY business day), provided that the sender maintains a machine record of
11 the completed transmission. For all claims arising out of or related to this Agreement, nothing in this
12 section establishes, waives, or modifies any claims presentation requirements or procedures provided by
13 law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government
14 Code, beginning with section 810).
15 36. SEVERABILITY
16 If any non-material term, provision, covenant, or condition of this Agreement is held by a
17 court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions shall
18 remain in full force and effect, and shall in no way be affected, impaired or invalidated.
19 37. GOVERNING LAW
20 Venue for any action arising out of or related to the Agreement shall only be in Fresno
21 County, California. The rights and obligations of the parties and all interpretation and performance of this
22 Agreement shall be governed in all respects by the laws of the State of California.
23 N
24 N
25 N
26 N
27 N
28 W
- 35 - COUNTY OF FRESNO
Fresno, CA
1 38. ENTIRE AGREEMENT
2 This Agreement, including all Exhibits (listed below), constitutes the entire agreement
3 between CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all
4 previous agreement negotiations, proposals, commitments, writings, advertisements, publications, and
5 understandings of any nature whatsoever unless expressly included in this Agreement.
6
Exhibit A— Scope of Work
7 Exhibit B — Full Service Partnership Service Delivery Model
Exhibit C — Medi-Cal Organizational Provider Standards
8 Exhibit D — Guiding Principles of Care Delivery
9 Exhibit E — Budgets
Exhibit F — Fresno County Mental Health Compliance and Code of Conduct
10 Exhibit G — Documentation Standards for Client Records
Exhibit H — Performance Outcome Measures
11 Exhibit I — State Mental Health Requirements
Exhibit J — Protocol for Completion of Incident Report
12 Exhibit K— Fresno County Mental Health Plan Grievances
Exhibit L — Fixed Asset Log
13 Exhibit M — National Standards for Culturally and Linguistically Approriate
14 Services
Exhibit N — Disclosure of Ownership and Control Interest Statement
15 Exhibit O — Certification Regarding Debarment, Suspension, and Other
Responsibility Matters — Primary Covered Transactions
16 Exhibit P — Self-Dealing Transaction Disclosure Form
Exhibit Q — Assessment Forms & Key Event Tracking Forms
17
18
19
20
21
22
23
24
25
26
27
28
36 - COUNTY OF FRESNO
Fresno, CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
3 CONTRACTOR: COUNTY OF FRESNO
Q CENTRAL STAR
BEHAYI VALALT i�F'�!, C.
5 By l--''" By I
6 al OdSupervisors
, Chairperson of the
d of the
7 Print Name: _K Yrif J)UnIn County of Fresno
8 P. y
Title:—P.L s t<�r o-f , f..
9 Chairman of the Board, or
President, or any Vice President
10
Date: / °l/ ATTEST:
1.1 Bernice E. Seidel
- Clerk of the Board of Supervisors
i 2 r ----' County of Fresno, State of California
13
By ram ,.19 Print Name: j 'r" � `t �,� By_��_ - % 1\
-\
Deputy
1.5 Title: Sc &C-r- '
Secretary (o orporation), or
16 any Assista Secretary, or
Chief Financial Officer, or
17 any Assistant Treasurer
18 Date:
19
20
Mailing Address:
21 1501 Hughes Way, Suite 150,
Long Beach, CA, 90810
22
23 FOR ACCOUNTING USE ONLY:
24 Organization: 56304471
25 Account/Program: 7295/0
26
2'7
28
Exhibit A
Page 1 of 18
Mental Health Services Act - Transition Age Youth
Mental Health Services & Supports and Housing Services Program
SCOPE OF WORK
ORGANIZATION/CONTRACTOR: Central Star Behavioral Health, Inc.
ADDRESS: 1501 Hughes Way, Suite 150, Long Beach, California 90810
SITE ADDRESS: 2140 Merced Street, Suite 101, Fresno, California 93721 and
2934 Fresno Street, Fresno, California 93721
SERVICES: Mental Health, Supports & Housing Services
TAY PROGRAM DIRECTOR: Nona Akopyan
Phone: 559-892-1128
Email: nakopyan@starsinc.com
REGIONAL DIRECTOR: Deborah T. Gatewood
Phone:559-892-1128
Email: dgatewood@starsinc.com
CONTRACT PERIOD: Effective upon execution — June 30, 2022
With two possible 12-month extensions
CONTRACT AMOUNT: FY 2018-19: $1,779,888
FY 2019-20: $2,670,548
FY 2020-21: $2,761,408
FY 2021-22: $2,843,832
FY 2022-23: $2,929,036
FY 2023-24: $3,003,727
COUNTY's DBH is contracting with CONTRACTOR to provide the following Full Service
Partnership (FSP) (attached as Exhibit B — FSP Service Delivery Model) mental health services
and supports, as well as housing services and supports to a minimum of one hundred forty-nine
(149) Transitional Age Youth (TAY) ages sixteen (16) to twenty-five (25) years. The TAY Program
shall deliver integrated mental health and supportive housing services to youth and young adults
who are aging out of the Juvenile Justice System, and are at risk of being hospitalized, homeless,
and/or incarcerated, and to individuals who are referred by the COUNTY Behavioral Health Court.
I. Background
The Mental Health Services Act (MHSA) Community Services and Supports (CSS)/Assertive
Community Treatment (ACT) and Housing Services FSP Program is a "whatever it takes"
program. TAY services shall be delivered as a FSP, outpatient mental health program serving
individuals between the ages of 16-25 with serious emotional disturbance (SED) or serious mental
illness (SMI), aging out of the Juvenile Justice System, and are at risk of being hospitalized,
homeless, and/or incarcerated, and to individuals who are referred by the COUNTY Behavioral
Health Court. Currently, through an ACT model, individuals receive on-going mental health
services, case management, group/individual/family therapy, medication/psychiatrist services and
affordable housing as well as the supports needed to achieve their goals. The TAY Program
focuses on client strengths and abilities to successfully gain independence and self—sufficiency in
Exhibit A
Page 2 of 18
Said TAY contracted services fall within the COUNTY's DBH Behavioral Health Clinical Care work
plan.
II. Services Start Date
CONTRACTOR shall begin services effective upon execution, once Medi-Cal billing site
certification is complete.
III. Target Population
The target population to be served shall be seriously mentally ill (SMI) or seriously emotionally
disturbed (SED) transitional age youth, ages 16-25, in addition to those SMI adult individuals, ages
18-25, that are aging out of the Juvenile Justice System, and may be referred by the COUNTY
Behavioral Health Court. Target enrollment capacity is 149. Of the 149 individuals that will receive
services under this Agreement, CONTRACTOR is to reserve openings for up to four (4) individuals
referred by the COUNTY Behavioral Health Court, ages 18-25 years. Participation in
CONTRACTOR's TAY Program is on the individuals' voluntary basis.
IV. Location of Services
TAY services shall be provided to youth and families throughout Fresno County. Services are
provided throughout Fresno County within the community as opposed to services being performed
at traditional mental health department offices or clinics in order to increase the frequency of
individuals needing services, as some are reluctant to seek services from traditional mental health
settings.
V. Description of Services
The MHSA TAY FSP program is a "whatever-it-takes" program to work toward the reduction in
homelessness, out of home placements, emergency room visits, inpatient psychiatric
hospitalizations, and/or incarceration for TAY and adults with SMI, including those adults with a co-
occurring substance use disorder who live in an impoverished, underserved, racially, and ethnically
diverse community. The TAY program shall use innovative interventions in comprehensive services
and housing to support the individual in recovery and self-sufficiency. Services shall be individual-
directed and shall employ psychosocial rehabilitation and recovery principles.
CONTRACTOR's TAY program shall be a partnership between the CONTRACTOR and the
COUNTY's DBH. CONTRACTOR shall provide and/or ensure linkages to outreach, personal
services coordination, food, clothing, housing, daily living skills, mental and physical health treatment,
substance abuse services, supported education and employment, vocational skills assessment and
development, transportation, advocacy, family and peer support. DBH staff shall oversee program
expenditures, outcomes, reporting, and contract monitoring.
In order to maintain fidelity to the FSP model, CONTRACTOR shall maintain a low mental health
staff (Case Managers and Clinicians) to client ratio of 1:15 maximum; however, the optimal staff to
client ratio is 1:12. CONTRACTOR shall provide an adequate number of trained staff dedicated to
the TAY Program, including a Psychiatrist to meet with individuals at a minimum monthly or more
often, if needed.
CONTRACTOR shall:
1. Maintain facilities and equipment, and operate continuously with the number and classification
of staff required described under this Agreement as listed in Exhibit B, "FSP Service Delivery
Model". If CONTRACTOR does not have the positions filled for these services as listed in
Exhibit B, CONTRACTOR shall notify COUNTY in writing within fifteen (15) days of the
Exhibit A
Page 3 of 18
vacancy and CONTRACTOR will include a written plan of action to continue the current level
of services.
2. Comply with any requirements of Fresno County's Mental Health Plan (FCMHP) as related to
performance outcomes, quality of life and/or customer satisfaction as a Medi-Cal
Organizational Provider, as described in Exhibit C.
3. Maintain knowledge of all provisions of the Mental Health Services Act (MHSA).
CONTRACTOR is required to maintain compliance with all MHSA reporting as outlined in the
Program Objectives.
4. Maintain its site-certified facility, which is to be easily accessible by public transportation and
centrally located near other supportive services locations. Changes to the location must be
submitted in writing and approved thirty (30) days in advance by DBH Director, or his or her
designee.
5. Be required to comply with all State regulations regarding State Performance Outcomes
measurement requirements, and participate in the outcomes measurement process as
required by the County. Bidder shall keep Department of Health Care Services (DHCS) Data
Collection Reporting (DCR) computer records up to date.
6. Participate in performance outcomes throughout each term of this Agreement. COUNTY staff
will 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 needed
information.
7. Required to annually attend the Compliance and Billing, and Documentation Trainings
provided by COUNTY's DBH.
8. Collaborate and provide linkages with other community agencies for the provision of non-
mental health services (Public Guardian, social services, physical health, etc.). These
services are particularly needed to reach people with co-occurring chronic or medical
conditions. Linkage must be provided for these clients to the full range of services. Client's
individual service treatment plans must include needed mental health services that are
recovery and wellness oriented.
9. Provide policies and procedures that include all safety, emergency and crisis procedures in
the field and in the CONTRACTOR's offices.
10. Provide individual service plans that will be culturally appropriate and individualized based on
the individual's culture and that clearly includes the individual's participation in the
development of the plan.
11. Ensure the client component of the Integrated Services and Supports Plan will describe the
Individual Service Plan. CONTRACTOR shall submit a description of their general services
plan and treatment chart. In addition, a treatment chart which meets Medi-Cal and Medicare
requirements will be maintained for each client.
10. Develop strategies to guide program services, which include the following components:
A. Client self-directed care plans (e.g., Wellness Recovery Action Plans or other
similar models);
B. Integrated physical and mental health services in collaboration with primary care
physicians;
Exhibit A
Page 4 of 18
C. Integrated services with law enforcement, probation and courts;
D. Education for clients and family, other caregivers, and other support persons as
appropriate to maximize individual choice about the nature of medications, the
expected benefits and the potential side effects as well as alternatives to
medications; and
E. Values-driven culturally competent evidence-based or promising clinical services
that are integrated with overall service planning and support housing, employment,
and/or education goals.
F. Ensure staff provides appropriate age, culture, gender and language services and
accommodations for clients that may have physical disabilities.
11. Once a referral is made to the TAY program, the CONTRACTOR will be responsible for
sending notification to COUNTY's DBH to track treatment progress. Assessments must be
conducted within ten (10) days of referral. Notifications will be sent at intervals designated by
COUNTY's DBH. The California Child and Adolescent Needs and Strengths — 50 (CANS 50)
and the Pediatric Symptom Checklist (PSC 35), along with Reaching Recovery (for adult
clients), will be used as the assessment and screening tools. CONTRACTOR will be
responsible for sending a disposition of discharge at the completion/termination of services.
12. CONTRACTOR's TAY program, services, and practices must align with DBH's Vision,
Mission, and Guiding Principles of Care Delivery.. DBH's principles of care delivery define
and guide a system that strives for excellence in the provision of behavioral health services
where the values of wellness, resiliency, and recovery are central to the development of
programs, services, and workforce. The principles provide the clinical framework that
influences decision-making on all aspects of care delivery including program design and
implementation, service delivery, training of the workforce, allocation of resources, and
measurement of outcomes. CONTRACTOR must also use any standardized tools, such as
the "Columbia Suicide Severity Risk", as directed by COUNTY's DBH. CONTRACTOR must
adhere to any and all applicable statutes as stated in MHSUDS Notice 18-011, "Federal
Network Adequacy Standards for Mental Health Plans (MHPs) and Drug Medi-Cal Organized
Delivery System (DMC-ODS) Pilot Counties."
13. Cultural competence is defined as the provision of services, which acknowledges and respects
cultural differences and community norms for racial, ethnic and gender groups. As related to
Cultural Competence, CONTRACTOR shall:
A. Provide necessary behavioral health and substance use disorder services in a culturally
competent manner which is fundamental in any effort to ensure success of high quality and
cost effective services by adhering to cultural competency standards and requirements.
B. Secure services of trained translators/interpreters as may be necessary. Interpreters/
translators shall be appropriately trained in providing services in a culturally sensitive
manner.
C. Shall, whenever possible hire racially and ethnically diverse community members and
client/family members to provide or assist with culturally competent, client and family-
driven mental health supportive services. CONTRACTOR will collaborate with members of
the various ethnic communities to share cultural perspective. Each ethnic community's
perspective on mental illness, co-occurring disorders, wellness and recovery may contain
different concepts and practices. By working together to explore these concepts
appropriate approaches will be developed for each ethnic/cultural group.
Exhibit A
Page 5 of 18
D. CONTRACTOR will be expected to adhere to the "National Standards for Culturally and
Linguistically Appropriate Services (CLAS) in Health and Health Care" as established by
the U.S. Department of Health and Human Services Office of Minority Health outlined in
Exhibit M. CONTRACTOR shall provide services within the most relevant and meaningful
cultural, gender-sensitive, and age-appropriate context for the target population.
CONTRACTOR shall give consideration to gender sensitivity and the differing
psychologies and needs of boys and girls when providing services. Items such as who is
the primary care giver, domestic violence, and women's health issues shall also be
considered in the provision of services.
E. The comprehensive bio-psychosocial intake process will include, as appropriate, the
assessment of client's racial, ethnic and gender needs.
F. As clinically appropriate and with engagement by the client/family, CONTRACTOR shall
utilize existing community supports to support cultural differences/needs. Community
based/support referrals may include, but not be limited to peer, cultural, ethnic and gender
support.
G. CONTRACTOR shall be responsible for conducting an annual cultural competency self-
assessment and provide the results of said self-assessment to the COUNTY. The annual
cultural competency self-assessment instruments shall be reviewed by the COUNTY and
revised as necessary to meet the approval of the COUNTY.
H. CONTRACTOR shall attend the COUNTY's Cultural Diversity Committee monthly
meetings, maintain its own cultural competence oversight committee, and develop a
cultural competency plan to address and evaluate cultural competency issues.
CONTRACTOR will provide specific services as it relates to mental health:
A. Families shall be contacted within forty-eight (48) hours of request for FSP services.
Service delivery should be prompt and reflect timeliness appropriate to the family's level of
urgency. All services should be scheduled according to the needs, preferences, ability,
and convenience of the family.
B. Provide crisis response and intervention twenty-four (24) hours per day, seven (7) days
per week throughout the year, including telephone and face-to-face contact as needed.
The following crisis response measures shall also be followed:
• CONTRACTOR will have a twenty-four/seven (24/7) phone number so that clients can
contact the program at any time;
• CONTRACTOR will make a reasonable attempt to have staff that knows the individual
client to respond in twenty-four/seven (24/7) crisis situations;
• Response to crisis shall be rapid and flexible;
• When crisis housing is necessary for short-term care and inpatient treatment (either
voluntary or involuntary), CONTRACTOR's staff shall collaborate with the treatment
staff in such facilities. Support shall be provided to the maximum extent possible,
including accompanying the client to the facility, remaining with the client during
assessment, and beginning the process of planning with the client for discharge to the
community as soon as possible.
C. CONTRACTOR will define, in detail, their policy regarding denial of referrals.
Exhibit A
Page 6 of 18
D. Have the flexibility to increase service intensity to a client in response to a client's needs.
A critical feature of the service delivery shall be the unified team approach, in which
multiple staff members with a diversity of skills address each client's mental health and
community life support needs in a comprehensive manner. Staff shall have the capacity to
provide as many contacts as needed to clients experiencing significant problems in daily
living. Staff shall provide a minimum of three contacts per week with each client and at
least one of those contacts will be face-to-face.
E. Operate a multidisciplinary treatment team including licensed/unlicensed mental health
professionals, nursing and psychiatric staff (psychiatrist) and mental health specialists,
peer/family specialists who will assist clients in developing their Individual Services Plan.
F. CONTRACTOR shall provide services in the areas of medication prescription,
administration, monitoring and documentation. CONTRACTOR's psychiatrist shall:
• Assess each client's mental illness and substance use disorder symptoms and
prescribe appropriate medication, as necessary. Medication for clients who do not
have a third party payor will be provided medication by the CONTRACTOR;
• Regularly review and document the client's mental illness and substance use disorder
symptoms as well as his/her response to the prescribed medications;
• Educate the client and client support system on the purpose of medication and any
side effects; and
• Monitor, treat and document any medication side effects.
G. Be available to provide symptom assessment, personal service coordination, and
supportive counseling to assist clients to cope with and gain mastery of symptoms and
disabilities due to mental illness and/or substance use disorder. These services shall
include, but not be limited to, the following:
• Ongoing assessment of the client's mental illness symptoms and response to
treatment;
• Education of the client regarding his/her mental illness and the effects (including side
effects) of prescribed medications;
• Symptom management efforts directed to help the client identify the symptoms and
their occurrence patterns and development of methods (internal, behavioral, adaptive)
to lessen their effects; and
• Provision, both on a planned and on an "as needed" basis, of such psychological
support as is necessary to help clients accomplish their personal goals and to cope
with the stresses of day-to-day living.
H. Provide training and instruction, including individual support, problem solving, skill
development, modeling and supervision, in home and community settings, to teach the
client to:
• Carry out personal hygiene tasks;
• Perform household chores, including housekeeping, cooking, laundry and shopping;
• Develop or improve money management skills;
Exhibit A
Page 7 of 18
• Use community transportation; and
• Locate, finance, and maintain safe, clean and affordable housing which is appropriate
to their levels of functioning.
I. Provide and/or help client access supported employment and supported education
programs services available in the community. Services provided through supported
employment and educational programs shall include, but not be limited to:
• Assessment of job-related interests and abilities based on a complete education and
work history. This assessment shall consider the effects of the client's mental illness
on employment, with identification on specific behaviors that interfere with the client's
work performance and development of interventions to reduce or eliminate the
behaviors;
• Assistance with each client's individual needs for job development, job seeking skills,
on-the-job assessment, referral to training, and support so that clients will acquire and
maintain appropriate job and social skills necessary to obtain and maintain
employment;
• Individual supportive counseling to assist the client to identify and cope with the
symptoms of mental illness that may interfere with his/her work performance;
• On-the-job or work-related crisis intervention; and
• Work-related supportive services, such as assistance with grooming and personal
hygiene, securing appropriate clothing, wake-up calls, and transportation.
J. Assign a staff member within twenty-four (24) hours of receiving a referral and begin the
development of a tentative client centered Personal Services Plan to meet the client's
identified needs.
K. Ensure that the team members are able to have on hand, in their possession, during
regular working hours (and when appropriate during on-call hours) an adequate amount of
petty cash with which to make emergency purchases of food, shelter, clothing,
prescriptions, transportation, or other items and services as needed for clients. This may
include security deposits, rent subsidy, and other items needed by clients. CONTRACTOR
will provide policies and procedures to COUNTY as to the handling of petty cash.
L. Link clients with an organization which provides representative payee services, for some
client's in accordance with sound accounting practices and when clinically indicated.
M. Link clients to appropriate social services, provide transportation as necessary, and link
the client to appropriate legal advocacy representation.
N. Develop and support the client's participation in recreational and social activities, positive
social relationships, and activities in a normative community setting. Staff shall provide
support and help individual clients to establish positive social relationships and activities in
community settings. Such services shall include, but not to be limited to, assisting clients
in:
• Developing social skills and, where appropriate, the skills to develop meaningful
personal relationships;
Exhibit A
Page 8 of 18
• Planning appropriate and productive use of leisure time including familiarizing clients
with available social and recreational opportunities and increasing their use of these
activities;
• Interacting with landlords, neighbors and others;
• Developing assertiveness and self-esteem; and
• Using existing self-help centers, such as Blue Sky Wellness Center, self-help groups
and other social, faith, and recreational groups to combat isolation and withdrawal
experienced by many persons coping with severe and persistent mental illness.
O. Provide alcohol, tobacco and other substance use disorder services as needed, in
accordance with harm reduction principles. This will include, but is not limited to, individual
and group interventions to assist clients in:
• Identifying alcohol, tobacco and drug abuse effects and patterns;
• Recognizing the interactive effects of alcohol, tobacco and drug use, psychiatric
symptoms, and psychotropic medications;
• Developing motivation for decreasing alcohol, tobacco and drug use;
• Developing coping skills and alternatives to minimize alcohol, tobacco and drug use;
• Achieving periods of abstinence and stability;
• Attending appropriate recovery or self-help meetings;
• Work with the client to reduce the level of risk associated with substance use and
support client in achieving stage matched change in substance use; and
• Achieving an alcohol, tobacco, and drug free lifestyle, if at all possible.
P. Provide information, in an educational format, on the use of alcohol, tobacco, prescribed
medications, and other drugs of abuse and the impact that chemicals have on the ability to
function in major life areas. Information shall also include eating disorders, gambling,
overspending, sexual and other addictions, as appropriate.
Q. Make appropriate referrals and linkages to addiction services that are beyond the outlined
wrap-around type services to individuals with coexisting alcohol, tobacco and drug abuse
and other addictive symptoms.
R. Minimize client involvement with the criminal justice system, with services to include, but
not be limited to:
• Helping the client identify precipitants to the client's criminal involvement;
• Providing necessary treatment, support and education to help eliminate any unlawful
activities or criminal involvement that may be a consequence of the client's mental
illness;
• Collaborating with police, court personnel and jail/prison officials and psychiatric staff
to ensure appropriate use of legal and mental health services; and
Exhibit A
Page 9 of 18
• Working with COUNTY jail mental health staff in planning for their release from
custody and transition back into the community (staff will pass Sheriff's Department
security screening in order to obtain passes to provide outreach linkage and
assessment services at the jail).
S. Provide support to the client's family and other members of the client's social network to
help them manage the symptoms and illness of the client and reduce the level of family
and social stress associated with the illness.
T. Assist client, family and other members of the client's social network to relate in a positive
and supportive manner through such means as:
• Education about the client's illness and their role in the therapeutic process;
• Supportive counseling;
• Intervention to resolve conflict;
• Referral, as appropriate, of the family to therapy, self-help and other family support
services; and
• Provision to the client's other support systems with education and information about
serious mental illnesses and treatment services and supports.
U. Coordinate services with other community mental health and non-mental health providers,
as well as other medical professionals. Methods for service coordination and
communication between CONTRACTOR and other service providers serving the same
clients shall be developed and implemented consistent with COUNTY confidentiality rules
and include the following:
a. Formal and informal affiliations with appropriate mental health, social services, health
care, substance use disorder, and other human service providers, and inpatient units;
b. Involvement of other pertinent agencies, the client's family, and members of the
client's social network in the coordination of the assessment, and in the development,
implementation and revision of service plans;
c. Advocacy for and assistance to clients to obtain needed benefits and services such as
supplemental security income, housing subsidies, food stamps, medical assistance,
and legal services;
d. Coordination of meetings of the client's service providers in the community;
e. Maintenance of ongoing communication with all other agencies serving the client
including hospitals, rehabilitation services and housing providers, as needed;
f. Maintenance of working relationships with other community services, such as
education, law enforcement and social services;
g. Coordination with existing community agencies to develop needed community support
resources including housing, employment options and income assistance; and
h. Maintenance of a clinical treatment relationship with the client on a continuing basis
whether the client is in the hospital, community, involved with other agencies or the
criminal justice system.
Exhibit A
Page 10 of 18
V. Network with peer support services and appropriate services offered through the Mental
Health Services Act (MHSA), as implemented.
W. CONTRACTOR will identify diversity of their enrolled clients, along with housing status,
identifying gender, ethnicity, date of birth and/or age and other demographics as requested
by COUNTY and maintain a database of targeted population.
X. Provide drug testing to dually-diagnosed clients on a random basis, as appropriate, as a
part of the Personal Services Plan and linking client to appropriate substance use disorder
treatment services.
Y. Ensure staff participate in education and training activities provided by the COUNTY, State
of California, and/or organizations to strive for best practices model.
Z. Provide assistance and advocacy in obtaining any available public benefits and accessing
needed behavioral health and physical health care for clients.
AA. Provide whatever direct assistance is reasonable and necessary to ensure that the client
obtains the basic necessities of daily life, including transportation. CONTRACTOR shall
have vehicles available to staff to transport clients to appointments and social group
activities. Bus token/passes will be made available by the CONTRACTOR to encourage
and empower client to utilize public transportation to their scheduled appointments.
BB. Enter monthly data required by State via the web-based data collection report (DCR)
operated by the State Department of Health Care Services (DHCS). CONTRACTOR is to
receive approval from DHCS prior to entering data.
16. CONTRACTOR will comply with data collection and reporting responsibilities:
A. Deliver all MHSA required reporting in data collection format that reflects MHSA and any
other government requirements in a timely and accurate manner. DHCS has identified
domains on which data must be captured by FSP's. CONTRACTOR will be required to
assign staff to data entry and input; contact the Performance Outcomes and Quality
Improvement Division of DHCS to schedule trainings; and establish procedures to complete
the MHSA Full Service Partnership Outcomes Assessment (FSP) forms.
B. Reports are to include: Changes to Client and Services Information (CSI) system
reporting, outcome assessments for FSP clients and notification of cost report changes,
annual updates and progress reports. COUNTY shall provide a timeline on when each
report is due to the COUNTY. COUNTY, at its sole discretion, may withhold future
amounts payable to CONTRACTOR until such time that all reports are satisfactorily
received by the COUNTY'S DBH.
C. CONTRACTOR shall maintain an up to date caseload record of all clients enrolled in
services, and provide client, programmatic, and other demographic information to the
COUNTY's DBH. Reports are to be submitted to COUNTY's DBH staff.
CONTRACTOR will compile quarterly reports indicating the total number of clients served
in a particular Fiscal Year, along with each quarter's target count versus the actual count
as shown below - "THREE-YEAR PLAN- QUARTERLY PROGRESS GOALS AND
REPORT, Estimated/Actual Populations served".
D. Ensure billable specialty mental health services meet any/all COUNTY, State, Federal
regulations including any utilization review, credentialing, site certifications, and other
quality assurance standards. Provide all pertinent and appropriate information in a timely
manner to COUNTY to bill Medi-Cal for services rendered. CONTRACTOR should also
Exhibit A
Page 11 of 18
ensure that private insurance and/or Medi-Care is properly billed prior to submitting Medi-
Cal claims to the COUNTY.
E. Refer clients who meet the criteria and are eligible for entitlement programs for
benefits/services. All clients currently in the program and any new clients to be enrolled
will go through Social Services to qualify for financial resources.
F. Ensure that all clients without financial resources apply for Medi-Cal and complete SSI
applications, establish benefits or have developed an alternative plan for eventually
assuming their own housing costs.
CONTRACTOR shall provide services as it relates to Wrap-Around services:
A. Provide Wrap-Around services, twenty-four (24) hours a day, seven (7) days a week.
These services will be comprehensive, home-based mental health treatment and case
management services that will support SED youth and SMI adults between the ages 16 to
25 years old in the least restrictive environment. Services are provided to:
• Families in which the TAY individual is at-risk for out-of-home placement;
• Families in which the TAY individual is returning to the home and community following
out-of-home placement;
• Families for whom stressors are negatively impacting child and family functioning;
• Young adults working towards independent living; and
• Young adults who are identified through the structured COUNTY Behavioral Health
Court program in collaboration with Probation, Courts, Public Defender, District
Attorney, Jail Behavioral Health Services and COUNTY's DBH.
Wrap-Around services staff will facilitate services coordination and communication among
all involved providers and agencies. Staff will identify and connect families with
natural/informal or cultural/traditional/agency-based support systems within their family or
community.
Collaborate and provide linkages with other community agencies for the provision of non-
mental health services (Public Guardian, social services, physical health, etc.). These
services are particularly needed to reach people with co-occurring, chronic or medical
conditions. Linkage must be provided for these clients to the full range of services.
Client's Individual Service Plans must include needed mental health services that are
recovery and wellness oriented.
B. Services will be intensive treatment and rehabilitation services to promote adaptive
functioning in the community and prevent unnecessary re-admissions to Institute of Mental
Disease's (IMD's), acute inpatient hospitals, or other higher levels of care.
Wrap-Around services shall include:
• The development of a client-centered personal service/care plan reflective of
behavioral health assessments (including risk assessments);
• The development, location, coordination, and maintenance of independent or other
appropriate housing for all clients within the community;
Exhibit A
Page 12 of 18
• The development, maintenance and involvement of all clients in lower levels of care in
a peer-to-peer support network and social engagement activities;
• The development and maintenance of a twenty-four/seven (24/7) crisis intervention
service;
• The development and maintenance of integrated mental health and substance use
disorder treatment services for all individuals with co-occurring disorders;
• The development and maintenance of supported employment and/or supported
education with involvement of all clients who can benefit from these services;
• The development and maintenance of"wrap around" funds to provide for the client's
immediate basic needs or to purchase specialized services that are required to reduce
the client's risk factors when no other funding source is available;
• The development and provision of family involvement/support services to all interested
families;
• The development and provision of case management services that will access all
entitlements or make referral to any support services for which a client is eligible;
• The development and provision of transportation and other support services clients
may need to access health care, mental health services, education, employment,
rehabilitation, peer support, recreational or other services within the community;
• The development and maintenance of a "representative payee" service for all clients
who would benefit from this service;
• The provision of integrated medical support services including psychiatric
assessments, psychopharmacological treatment, and education and monitoring for all
clients;
• The provision of all other mental health services that may be needed or required by
clients; and
• The integration of mental health recovery principles and practices promoting
employment; and facilitation of a client-centered approach in all treatment services.
CONTRACTOR shall provide the following specific services as it relates to housing:
CONTRACTOR will empower clients and family members to take an active role in the recovery
process. CONTRACTOR will provide housing options and maintain clients in independent
living by providing needed services, accessing resources and encouraging clients to be
independent, productive and responsible. Clients in independent housing will develop a plan
for assisting in paying their own housing costs. Clients will assume responsibility for housing
costs when deemed ready and appropriate. CONTRACTOR shall ensure that all clients
without financial resources apply for Medi-Cal and complete SSI applications, establish
benefits or have developed an alternative plan for eventually assuming their own housing
costs. Housing services shall be provided for TAY clients who are emancipated minors or
adults, age 18-25. Housing options and opportunities will also be available to include the
parenting TAY population. Money will be available for temporary emergency housing.
Housing services for those that are transitioned from current services are to be closely
monitored for any needed change in level of housing; every effort will be made to engage the
TAY enrollee in order to maintain their current housing, if clinically appropriate for client.
Exhibit A
Page 13 of 18
A. CONTRACTOR's housing team shall provide whatever direct assistance is reasonable and
necessary to ensure that the client obtains the basic necessities of daily life, including but
not limited to:
• Safe, clean, affordable housing;
• Food and clothing;
• Medical and dental services; and
• Appropriate financial support, which may include housing deposits, Supplemental
Security Income, Social Security Disability Insurance, General Relief, and money
management services.
B. CONTRACTOR shall have efficient, rapid access to client assistance funds for security
deposits, purchase of furniture, and other items needed by clients.
C. CONTRACTOR will provide housing services as needed by clients, ensuring that clients
maintain their respective housing and utilize supportive housing resources provided
through the CONTRACTOR by:
• Providing training and assistance to clients in locating, securing and inhabiting
housing which is appropriate to their levels of functioning;
• Providing training and instruction, including individual support, problem solving, skill
development, modeling and supervision, in home and community settings, to teach the
client to finance and maintain safe, clean, and affordable housing; and
• Providing varied living situations that expand levels of housing that will encompass
levels from supportive independent living to individual independent housing for the
client/families. The goal is to have every client in supported independent and
independent housing, as appropriate, with proper supports, as soon as possible.
D. Establish a program to provide rent subsidies for independent housing when the cost of
housing exceeds the client's social security or other income.
E. Provide at least one (1) staff person who is the designated Housing Coordinator to assist
clients in coordinating rents, leases, general relief and work with housing
owners/landlords. The Housing Coordinator could potentially have other responsibilities.
F. Meet monthly with MHSA staff, or as appropriate, with staff to discuss and resolve any
issues and/or any client status changes. Status changes include but are not limited to
hospitalization, incarceration, crisis calls, housing etc.
VI. Staffing
CONTRACTOR shall provide the following staffing components:
A. CONTRACTOR must have a clear plan for engaging and providing services to TAY clients,
adults and their families that reside in rural Fresno County.
B. CONTRACTOR shall provide staff work schedules. Staff work schedules shall be
responsive to client needs and shall permit staff to work evenings and weekends. During
off-hour periods (5:00 pm — 8:00 am), staff shall maintain on-call coverage and shall be
available to respond immediately to clients during off-hour periods, clinical/psychiatric staff
will be available to provide psychiatric support. At least 65% of staff time shall be direct
Exhibit A
Page 14 of 18
service time on behalf of the client with services being provided in community settings.
CONTRACTOR will consider having some staff that are regularly scheduled to work after
regular business hours and/or on the weekends in order to reduce over-time costs and in
order to provide a more flexible treatment schedule for clients.
C. CONTRACTOR's Personal Services Coordinator's (PSC) staff shall be available to provide
crisis intervention twenty-four (24) hours per day, seven (7) days per week throughout the
year, including telephone and face-to-face contact as needed. Response to crisis shall be
rapid and flexible. CONTRACTOR shall collaborate with facilities and designated staff to
provide emergency placement should crisis housing, short-term care and inpatient
treatment (voluntary or involuntary) be needed. CONTRACTOR's staff shall provide
support to the maximum extent possible, including accompanying the client to the facility
and remaining with the client during the assessment. As soon as possible CONTRACTOR
staff shall work with the client and the treating facility to begin the process of planning for
discharge and return to the community.
D. CONTRACTOR shall hire staff that is bilingual/bicultural, based on client's needs, in order
to provide access to TAY individuals in their preferred language and to help to decrease
and eliminate disparities in access and quality of care for Latino, Southeast Asian, and
African-American communities.
E. CONTRACTOR shall provide services to transition age youth, adults, and their families in
all of Fresno County. CONTRACTOR must have a clear plan for engaging and service
provision for those that reside in rural Fresno County.
F. CONTRACTOR shall provide services in the areas of medication prescription,
administration, monitoring and documentation. The psychiatrist shall:
• Assess each client's mental illness symptoms and behavior and prescribe appropriate
medication as necessary. Medication for clients who do not have a third party payor
will be provided medication and paid by the COUNTY, as appropriate (COUNTY
approval is required prior to prescribing medication to those clients that have no third
party payor);
• Be familiar with the most recent psychiatric literature in order to be educated regarding
the best treatment for TAY clients;
• Be cognizant of medication costs and be willing to prescribe generic and other less
expensive medications as long as there is no negative impact on the client;
• Regularly review and document the client's mental illness symptoms as well as his/her
response to the prescribed medications;
• Educate the client and social support persons on the purpose of medication and any
side effects;
• Monitor, treat and document any medication side effects; and
• Meet with each client at a minimum once monthly basis or more frequently, depending
on each client's situation.
G. The ratio of Case Managers to clients will be no more than one (1) to twelve (12) clients
(1:12).
H. CONTRACTOR shall evaluate the staff's competency for performance purposes and
establish medication policies and procedures, which identify processes to administer
Exhibit A
Page 15 of 18
medications to clients and train other staff and social support persons regarding
medication education, medication delivery, medication side effects, observation of self-
administration of medication and medication monitoring.
I. Staff shall assess and document the client's mental illness symptoms and behavior in
response to medication and monitor for medication side effects during the provision of
observed self-administration and during ongoing face-to-face contacts.
J. Incorporate client-directed, psychosocial rehabilitation and recovery principles and the use
of a peer-to-peer support network that includes hiring recovering clients and/or family
members. Staff shall employ harm reduction in philosophy and motivational interviewing
techniques and principles. CONTRACTOR shall provide training in harm reduction and
motivational interviewing so that staff are fully aware of these methods.
K. CONTRACTOR shall have at least three (3) mental health specialists, e.g., "Mental Health
Advocate", "Peer Advocate," "Family Advocate." CONTRACTOR may determine the exact
job titles for these specialists. At least one of the mental health specialists shall be a
primary client. The mental health specialists shall be a current Mental Health client and/or
family member.
The client and/or family member will have demonstrated one (1) year of volunteer or paid
experience working with individuals with serious and persistent mental illness to meet the
requirements of a mental health specialist. A mental health specialist shall be regarded as a full,
professional member of the clinical team, function under the same job description as other mental
health specialists, and receive salary parity.
The mental health specialists shall not provide services to their respective family members nor
serve on a team, which provides services to a family member/significant other. Decisions
regarding disclosure to clients, their families and significant others, that a staff person is
himself/herself a client or a family member, shall respect the individual preference of that staff
person and be made in consultation with the staff person's supervisor and/or program director.
CONTRACTOR may hire more than one mental health client and/or family member.
VII. Hours of Operation
CONTRACTOR will be required to be available to provide services twenty-four (24) hours per day,
seven (7) days per week throughout the year, including telephone and face-to-face contact as
needed.
VIII. Average Client Length of Stay
Currently, clients are typically engaged in services for a duration of 2-3 years.
IX. Program Outcomes
COUNTY's DBH is dedicated to supporting the wellness of individuals, families and communities
in Fresno County who are affected by, or at the risk of, mental illness and/or substance use
disorders through the cultivation of strengths toward promoting recovery in the least restrictive
environment.
CONTRACTOR will be required to submit measureable outcomes on an annual basis, as
identified in the Departments Policy and Procedure Guide (PPG) 1.2.7 Performance Outcomes
Measures, attached as Exhibit H. 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
Exhibit A
Page 16 of 18
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.
1. Effectiveness: A performance dimension that assesses the degree to which an intervention
or services have achieved the desired outcome/result/quality of care through measuring
change over time. The results achieved and outcomes observed are for persons served.
Examples of indicators include: Persons get a job with benefits, or receive supports needed to live
in the community, increased function, activities, or participation, and improvement of health,
employment/earnings, or plan of care goal attainment.
2. Efficiency: Relationship between results and resources used, such as time, money, and
staff. The demonstration of the relationship between results and the resources used to
achieve them. A performance dimension addressing the relationship between the
outputs/results and the resources used to deliver the service.
Examples of indicators include: Direct staff cost per person served, amount of time it takes to
achieve an outcome, gain in scores per days of service, service hours per person achieving some
positive outcome, total budget (actual cost) per person served, length of stay and direct service
hours of clinical and medical staff.
3. Access: Organizations' capacity to provide services of those who desire or need services.
Barriers or lack thereof for persons obtaining services. The ability of clients to receive the
right service at the right time. A performance dimension addressing the degree to which a
person needing services is able to access those services.
Examples of indicators include: Timeliness of program entry (From 1 st request for service to 1 st
service), ongoing wait times/wait lists, minimizing barriers to getting services, and no-
show/cancellation rates.
4. 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 may additionally
propose other performance and outcome measures that are deemed best to evaluate the services
provided to clients and/or to evaluate overall program performance. DBH may adjust the
performance and outcome measures periodically throughout the duration of the agreement, as
needed, to best measure the program as determined by the COUNTY. CONTRACTOR will be
required to utilize and integrate clinical tools as directed by DBH.
CONTRACTOR must utilize a computerized tracking system with which performance and outcome
measures and other relevant data, such as demographics, will be maintained. The data tracking
system may be incorporated into the selected CONTRACTOR's Electronic Health Record (EHR)
or be a stand-alone database. COUNTY's DBH must be afforded read-only access to the data
tracking system, if applicable.
Exhibit A
Page 17 of 18
Additional reporting is required for FSPs by the DHCS. DHCS uses the FSP Data Collection and
Reporting (DCR) system to ensure adequate research and evaluation, regarding the effectiveness
of services being provided and the achievement of the outcome measures. CONTRACTOR will
need to report client/partner information and outcomes of the FSP program directly into the DCR
system. Data will be submitted through an online interface using specific forms (see Exhibit Q).
The Partnership Assessment Form gathers baseline information about the partner, and is
completed once the partnership is established. Key Event Tracking provides a snapshot of
changes in key quality of life areas and is tracked on a continuous basis throughout the course of
the FSP. The Quarterly Assessment collects updated information about changes in quality of life
areas and is completed every three months from the date the partnership is established.
In addition to the requirements set above, the following items listed below represent program
goals to be achieved by CONTRACTOR. The program's success will be based on the number of
goals it can achieve, resulting from performance outcomes. CONTRACTOR will utilize a
computerized tracking system with which outcome measures and other relevant client data, such
as demographics, will be maintained.
Regarding Crisis Interventions and Recidivism:
Each enrollee will have no more than six (6) key events (specifically incarceration, homelessness,
and crisis or inpatient hospitalization admission) during the first six (6) months in the TAY
program. There will be a reduction of key events for enrollees tracked as:
• No more than three (3) key events (incarceration, homelessness, and crisis or inpatient
hospitalization admission) during months six to twelve (6-12) of enrollment in program.
• No more than one (1) key event (incarceration, homelessness, and crisis or inpatient
hospitalization admission) during months thirteen to eighteen (13-18) of enrollment in
program.
A. FSP will show zero percent (0%) days of homelessness after being enrolled in the
program, unless client declined housing assistance. CONTRACTOR shall notify DBH of
client's decline and document accordingly. CONTRACTOR must have clear
documentation of efforts to house clients in appropriate setting.
B. FSP will show a ninety percent (90%) reduction in client's days in inpatient psychiatric
hospitalizations after being enrolled in FSP compared to the year before being enrolled in
the FSP.
C. FSP will show a ninety percent (90%) reduction in client's days incarcerated after being
enrolled in FSP compared to the year before being enrolled in the FSP.
Regarding Linkages and Referrals:
A. Within ninety (90) days of being enrolled in the FSP, one hundred percent (100%) of
clients who did not have SSI will have made applications completed to receive SSI.
CONTRACTOR will provide this data as requested.
B. Within six (6) months of being enrolled in the FSP, one hundred percent (100%) of clients
will have linkages to and documentation of a Primary Care Physician.
C. Within thirty (30) days of enrollment, one hundred percent (100%) of clients will have
participated in forming their Individualized Service Plan.
D. Within one hundred twenty (120) days of enrollment, one hundred percent (100%) of
clients will be provided/linked to job coaching activities.
Exhibit A
Page 18 of 18
E. Where appropriate, within ninety (90) days of enrollment, at least seventy-five percent
(75%) of applicable clients will have been offered the opportunity to participate in
Supportive Education and Employment Services. Within one hundred twenty (120) days of
enrollment, at least ninety-five percent (95%) of applicable clients will have been offered
the opportunity to participate in Supportive Education and Employment Services.
Outcomes will be monitored to see if the client has meaningful use of their time, stays in school or
maintains employment, hospitalizations and incarcerations are reduced as well as homelessness.
COUNTY's DBH will use State criteria for measuring these outcomes. CONTRACTOR will be
monitored regarding services delivered and if they meet the goals of the MHSA.
This program will use an effective method likely to bring about intended outcomes, based on one
of the following standards, or a combination of the following standards (as defined by current
MHSA regulations):
• Evidence-based practice standard
• Promising practice standard
• Community and or practice-based evidence standard
CONTRACTOR will collect all data and fulfill all reporting requirements as specified in the
applicable MSHA regulations related to the program type, strategies, and standards indicated
above or as indicated in MHSA regulations. CONTRACTOR will work with COUNTY to ensure
data, outcomes, and reports are included in all required MHSA reports, plans, and updates.
Current MHSA Regulations can be found at the following website:
http://mhsoac.ca.gov/laws-and-regulations
CONTRACTOR should understand all MHSA regulations to ensure they have the organizational
capacity to record, track, and report all required elements.
EXHIBIT B
Page 1 of 4
FULL SERVICE PARTNERSHIP SERVICE DELIVERY MODEL
This document outlines requirements for Full Service Partnership collaborations and can be
found in its entirety at http://www.dhcs.ca.gov/services/MH/Documents/FSP FAQs 04-17-
09.pdf
Full Service Partnerships (FSP) are designed as a partnership between enrollees and the
service provider. The FSP service delivery ethic incorporates recovery and cultural competence
into the services and supports offered to consumers. In this partnership, the service provider
commits to do "whatever it takes" and to "meet the client where they are" in order to assist the
enrollee achieve their personal recovery/resiliency and wellness goals.
1. The Target Population is consistent with the population identified in the Fresno
County MHSA Community Planning Process.
The target population must meet requirements for SMI/SED diagnosis; and must address
reduction of specific ethnic disparities, as indicated in the MHSA Community Services and
Supports plan.
The target population will include individuals who are not currently served and meet one or
more of the following criteria:
• Homeless
• At risk of homelessness— such as youth aging out of foster care or
• persons coming out of jail
• Involved in the criminal justice system (including adults with child protection issues)
• Frequent users of hospital and emergency room services
or are so underserved that they are at risk of:
• Homelessness —such as persons living in institutions or nursing homes
• Criminal justice involvement
• Institutionalization
Diagnoses that serve as criteria for inclusion in the target population will be based on definitions
found in 5600.3 California Welfare and Institutions Code defining severe mental disorder. The
operational definition of"diagnosis" for programs serving the chronically homeless may also
include: co-occurring disorders, personality disorders, general anxiety/mood disorders, and Post
Traumatic Stress Disorder.
2. FSP Program Components:
All MHSA FSP Programs must include the following in their program descriptions:
• Providers who are part of the multidisciplinary, community based "treatment"
teams serve as an ally to the consumer's recovery process. The partnership allows
clients and family members opportunities for informed choice.
o The team description must demonstrate commitment and capacity to do
"whatever it takes" to assist the enrolled member, specifically:
■ Low Mental Health staff(Case Managers or Clinicians) to client ratio of
(1:15) maximum; however, the optimal staff to client ratio is (1:12).
■ 24/7 availability of the multidisciplinary team.
■ Team culture is created where each member of the team knows each
client and the clients are familiar with each member of the team.
EXHIBIT B
Page 2 of 4
■ Members of the team speak the client's language, are familiar with
community resources that reflect the healing beliefs of the client's culture,
and are positioned to assist the client make meaningful connection with
those resources.
■ Crisis response comes from a person known to the client.
■ Staff is given the administrative flexibility and flex-funding to connect
consumers with non-mental health services and same day needs.
Examples include: housing; primary care; dual disorder services;
education services and supports; vocational services and supports; payee
services/benefits advocacy; community recreational activities (YMCA
classes, libraries, movie theaters, etc.); social services; food;
transportation; and clothing.
■ Availability of Integrated Dual Diagnosis Treatment or other dual recovery
intervention that will provide effective treatment for the target population.
• Outreach and engagement. The team's outreach and engagement strategy must be
voluntary and driven by the values of client culture. This means that the individuals
served will be engaged "where they are" in terms of their community location, their need
for clinical and non-clinical services/supports and their phase of recovery. Outreach
workers will have culturally competent language skills and will function as an ally to the
client's decision to receive services. Peer Support will be included in the outreach and
engagement of new clients.
• Procedures for enrollment and dis-enrollment will be easily understood, clearly
communicated and non-coercive. Enrollment is voluntary. A condition of enrollment is
that the client indicates that they want services from the assertive-community treatment
model team.
• Each adult, older adult, and transition age youth enrollee must have a Personal
Service Coordinator (PSC). The PSC is an ally to the enrollee and acts as a "single
point of responsibility" within the multidisciplinary team for coordinating services and
supports.
"Personal Service Coordinators (PSCs) for adults— case managers for children and
youth—must have a caseload that is low enough so that: (1) their availability to the
individual and family is appropriate to their service needs, (2) they are able to provide
intensive services and supports when needed, and (3) they can give the individual
served and/or family member considerable personal attention... PSCs/case managers
must be culturally competent, and know the community resources of the client's racial
ethnic community." (Source: DMH Planning Requirements, Section III Identifying
Populations for Full Service Partnerships, Aug 2005)
• Each enrollee must have an Integrated Services and Supports Plan (ISSP) that is
developed with their Personal Services Coordinator. This ISSP is a planning tool
that builds on the individual's strengths. It includes goals and provides a map of the
steps that the enrollee identifies as necessary to move along his/her recovery path.
"Integrated Services and Supports Plans must operationalize the five fundamental
concepts (identified in Section Three of this Exhibit B) and should reflect community
collaboration, be culturally competent, be client/family driven with a
wellness/recovery/resiliency focus and they must provide an integrated service
experience for the client/family. In addition, the ISSP will be person/child-centered, and
give individuals and their families'sufficient information to allow them to make informed
choices about the services in which they participate. Services should also include
linkage to, or provision of, all needed services or benefits as defined by the client and or
EXHIBIT B
Page 3 of 4
family in consultation with the PSC/case manager. This includes the capability of
increasing or decreasing service intensity as needed." (Source: DMH Planning
Requirements, Section III Identifying Populations for Full Service Partnerships, Aug
2005)
• Peer support services will be made available to the client. At least two (2) staff[a
minimum of one (1) FTE] who act in peer support roles will be employed in each MHSA
program.
o The enrollee is given significant access to peer recovery and self-help services.
Tools such as Advanced Directives are made available to adult and older adult
clients, and Wellness Recovery Action Plans (WRAP) are made available to
adult, transition age youth and older adult clients.
o Peer Counselors are included as equal partners in the multidisciplinary team, and
play a critical role in developing the recovery culture and client orientation of the
team.
3. The Five (5) Core MHSA Concepts are embedded in each program.
Concept 1: Recovery/Resiliency Orientation:
FSPs will embody the values of recovery and resiliency (i.e., hope, personal
responsibility, self-advocacy, choice, respect) and the program principles of recovery
and resiliency, including:
• Client-driven goal setting and Individualized Services and Supports Plans.
• Providers are allies to the client's recovery process.
• A harm-reduction approach to substance abuse that encourages recovery
and abstinence but does not penalize consumers or withdraw help from them
if they are using.
• A built in understanding and expectation of setbacks as part of recovery.
• Links to a range of services that are part of the individual's "pathway to
wellness" (i.e., employment, health care, peer support, housing, medications,
food and clothing).
Concept 2: Cultural Competence Orientation: The program's structure, staffing and
service delivery values will reflect the cultural values and orientation of the program's
target populations.
The FSP program will embody principals of cultural competence including:
■ Diverse staff, representative of the primary ethnic groups to be reached through the
program
■ Staff trained regarding common access barriers for racial and ethnic groups targeted
(including the impact of housing discrimination)
■ Links to community-based organizations that share the healing beliefs and practices
of ethnic communities served by the FSP.
The FSP program must also be able to deal with gender and sexual orientation diversity.
Training in sensitivity to gender and sexuality issues is a key component for staff on the
team.
Concept 3: Community Collaboration: FSP Collaborations ensure that community
resources are made available to enrollees. These collaborations include subcontracts
between the CONTRACTOR and other agencies, memoranda of understanding with
community non-profits and businesses regarding providing services to clients, and
EXHIBIT B
Page 4 of 4
informal relationships built between FSP staff and community stakeholders that result in
improved access and decreased discrimination.
Concept 4: Client/Family Driven program: In FSPs, the Integrated Services and
Supports Plan (ISSP) is used by adult clients and families of children and youth to
identify their needs and preferences which lead to the services and supports that will be
most effective for them. Providers work in full partnership with clients to develop these
ISSPs. Their needs and preferences drive the policy and financing decisions that affect
them.
Concept 5: Integrated Service Experience: FSP programs were incorporated into the
MHSA to ensure that these dollars funded "integrated service experiences". This means
that services are "seamless" to clients and that clients do not have to negotiate multiple
agencies and funding sources to get critical needs met and to move towards recovery
and develop resiliency. Services are delivered, or at a minimum, coordinated through a
single agency or a system of care. The integrated service experience centers on the
individual/family, uses a strength-based approach, and includes multi-agency programs
and joint planning to best address the individual/family's needs using the full range of
community-based treatment, case management, and interagency system components
required by children/transition age youth/adults/older adults.
EXHIBIT C
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
EXHIBIT C
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation,
the provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Mental Health's
day treatment requirements. The COUNTY shall review the provider's written program
description for compliance with the State Department of Mental Health's day treatment
requirements.
12. The COUNTY may accept the host county's site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example: conversion
from a non-profit status).
• The provider adds day treatment or medication support services when medications shall be
administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some physical plant
changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or
members of the community.
Exhibit D
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
• Deliver quality care
• Maximize resources while focusing on efficiency
• Provide an excellent care experience
• Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1. Principle One -Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
1
rev 2017 Dec
Exhibit D
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2. Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3. Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4. Principle Four- Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person's quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5. Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
2
rev 2017 Dec
Exhibit D
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
6. Principle Six- Culturally Responsive
o Values, traditions, and beliefs specific to an individual's or family's culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7. Principle Seven -Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8. Principle Eight- Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9. Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client's stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
3
rev 2017 Dec
Exhibit D
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
10. Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11. Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
4
rev 2017 Dec
Exhibit E
Page 1 of 22
County of Fresno-Transitioned Age Youth (TAY) Services-Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY18119(Nov. 1,2018 -Jun. 30,2019)through FY 23124
BUDGET NARRATIVE -EXPENSES
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes &Employee Benefits -Line Items 0001-0042
Program Director: 1 FTE $90,000 with 3%to 4%annual increase for the next 5 years. Will oversee all staff and program.
He/she oversees Supervisors who directly manage these programs or provides direct management in their absence. The
Program Director will also create and update policies and procedures, review risk management and safety systems,
oversee and coordinate quality assurance and manage the day to day operations.
Mental Health Professionals-Supervisors: 2 FTE's$82,000 per FTE with 3%to 4%annual increase for next 5 years.
This position will provide clinical oversight of program and service delivery within the FSP program. The Supervisor will
direct the provision of mental health services; implement recovery based psychosocial programming to optimize TAY
strengths, skills, and partnerships with family, community and staff; and, assure that TAY needs are being met through
program activities while adhering to quality standards and best practices.
Mental Health Specialists: 5 FTE's$52,250 per FTE with 3%to 4%annual increase for the next 5 years. These positions
coordinate team-based care and lead the FSP team regarding service delivery based on participant voice. Mental Health
Specialists conduct initial and ongoing assessments and collect all documentation needed to develop care plans with TAY
and support people: provide community-based strength-based services for at-risk youth, and families by incorporating
evidence based practices, such as Transition to Independence Process (TIP), Trauma Informed Care (TIC), and
Motivational Interviewing. Mental Health Specialist lead case coordination process and provide individual and group
therapy, crisis intervention,family therapy, case management, and family support.
Personal Service Coordinators: 7 FTE's$37,000 per FTE with 3%to 4% annual increase for the next 5 years.This
position has primary responsibility as an FSP team member for using their lived experience and knowledge of mental
health recovery, and will serve as a Transition Facilitators assisting consumers to plan and progress in recovery. Personal
Service coordinators will serve as role models, companions ,educators and other service systems to provide outreach and
engagement, support, and advocacy to youth.
Housing and Employment Resource Specialist: FTE 1 $42,000 with 3%to 4%annual increase for the next 5 years.
The Housing/Employment Specialist works directly with TAY to help meet their service and resource needs, including
housing, educational services,job training,transportation, and other support services. This position develops relationships
with housing resources and community agencies, conducts vocational/job assessments,works with potential employers
and employment service providers, and helps TAY further their education. The Housing and Employment Resource
Specialist will regularly share and educate other staff about available housing and other resources.
Peer Specialist: 1 FTE $34,000 with 3%to 4%annual increase for the next 5 years. This position requires extensive
knowledge of community programs and resources as a mental health consumer. The Peer Specialist's primary
responsibility as an FSP team member is to navigate the peer support, wellness services and community supports. They
will teach clients about wellness and independent living skills. They will support clients' movement toward recovery, and in
pursuing meaningful roles in their lives, separate from their illness.
Family Partner: 1 FTE $34,000 with 3%to 4% annual increase for the next 5 years. This position's primary responsibility is
to the TAY and their families as equal partners in the planning, development and implementation of services. They will be
responsible for working with the TAY and families/caregivers and other loved ones to provide support, education and
advocacy. The position assists families to connect to community services and supports.
LVN/LPTs: 2.5 FTE's$49,000 per FTE with 3%to 4% annual increase for the next 5 years. . The LVN's will provide
nursing assessments, dispense medications, and monitor side effects. LVN's will also complete medication
intake/preparation for psychiatric care/evaluations and coordinating with psychiatric provider; evaluating for potential
medication side effects and report to psychiatric provider; coordinate resident care by maintaining direct contact with
psychiatric provider; and ensuring medication administration protocols are met.
Exhibit E
Page 2 of 22
Receptionist/Clerk: 1 FTE$31,200 with 3%to 4%annual increase for the next 5 years. This position will be the first point
of contact for visitors entering the facility, answer and respond to or direct all incoming calls, schedule appointments and
group services for the FSP team when needed. This position will also perform clerical and administrative tasks including
data collection and entry, general clerical functions and finance support.
Billing Clerk: .5 FTE$17,784 with 3%to 4%annual increase for the next 5 years. This position will complete Medi-Cal,
Medicare and other billing and reporting functions in compliance with all state and county requirements. Enters data and
monitors accuracy of data collection in EMR and data entry duties to meet BHCS billing and reporting requirements.
Training Coordinator: .25 FTE $13,000 For scheduling and managing training and professional development activities.
Quality Assurance Coordinator: .25 FTE$17,000 Oversees Quality Assurance processes, including audits, utilization
Review tracking reports and forms, creating reports and general QA tasks.
Human Resources Coordinator:.25 FTE$12,500 Responsible for recruitment, on/off-boarding, and maintenance of
credentialing files for licensed/certified staff.
Payroll Taxes -10% of payroll based on 6.2%for OASDI, 1.45%for FICA/MEDICARE, and 2.35%for SUI and FUTA.
Employee benefits equal 16.1%to 17.75%
Retirement-based on 2.1%to 2.25%for ESOP and 401 k employer match.
Workers Compensation-based on 3%of payroll.
Health Insurance (medical, vision, life, dental)based on 11%to 12.5% of payroll.
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 22/23
$ 921,144 $ 1,448,686 $ 1,502,887 $ 1,547,972 $ 1,594,412 $ 1,642,244
Facilities/Equipment Expenses-Line Items 1010-1014
Rent-$66,000-$108,747 based on office space of 5000 square feet with a cost of$1.65 per month per square feet with a
1%to 3% annual increase in the next 5 years.
Leased equipment-$8,000-$12,859 for copier lease with a 1%-3% increase in year 4-6.
Utilities-$7,667- 13,073 with 1%-3% annual increase for next 4 years. Utilities include electric, gas, water and trash.
Building Maintenance-$12,667-$14,337 for janitorial services and other maintenance with 3%annual increase in Years
3-6. Year 1 includes$7,000 for one time changes to office space.
Equipment purchase-includes office equipment and IT equipment and software. Year 1 is$122,130 based on $50,000
for office furniture and $72,130 for laptops and PC for 22 employees, server and cabling for the new facility. In Years 2-6
office equipment purchases range from $5,200 to$6,886 and IT hardware and software equal$22,200 to$24,229.
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 216,463 $ 162,805 $ 165,369 $ 167,547 $ 174,884 $ 180,131
Operating Expenses -Line Items 1060-1079
Telephone-$24,587-$39,127 for Iandlines, internet, and wireless access($24,160 to$26,025)and employee cell phone
reimbursement($12,720-$13,102) based on 16 employees for$60 per month and one employee for$100 per month with
2% -3% increase in Year 2-6.
Postage-$600-$1,033 to for USPS and other delivery services. Budget includes 2%-3% annual increase in the next 5
years.
Publications-$800-$1,377 for subscriptions for staff training material. Budget includes a 2% -3% annual increase in the
next 5 years.
Office Supplies&Equipment-for office supplies, shredding services, postage meter rental. Year 1 is$8,610 includes
approximately$1,000 for one time office supply purchases. Years 2-6 average approximately$11,500 and Year 5 is
$12,915 for replacement of equipment.
Food -$1,600-$2,755 for water filtration system cost and coffee supplies. Budget includes 2%-3%annual increase in
the next 5 years.
Program Supplies-Therapeutic$5,333-$9,185 for client hygiene supplies, medical supplies and psychological supplies
for clients. Budget includes 2%-3% increase in the next 5 years.
Exhibit E
Page 3 of 22
Staff Mileage/vehicle maintenance -$31,423-$53,223 which is based on$39,240 for staff mileage for 15 employees for
400 miles per month at .545 cents per mile, and$9,000 for gas, maintenance, insurance and registration for van. Budget
includes 2%-3% annual increase in the next 5 years.
Staff Travel (Out of County)-$2,333$3,605-for travel to training conferences and corporate office for meetings.
Staff Training/Registration-$4,800-$8,266 for staff training. Budget includes 2%-3% annual increase in the next 5
years.
Other-Program Services: $27,713-$68,859 is comprised of the SBHG corporate and regional support in the numerous
areas including support from the Senior Administrator as well as services provided for Program Development and
Evaluation, Quality&Compliance, and Training. There is a significant cost advantage to all the SBHG company programs
in sharing these costs rather than building them into each program. SBHG support provides oversight of all of our
programs to ensure consistency with our standards and policies and procedures.The cost of this support is shared by all
programs and is budgeted at approximately 2%to 3%of total expenses less life domain funds.
Other-Drug testing -$21,600-$36,477 for drug testing of 30%of clients each month at a cost of$60 per test. Budget
includes 2%-3% annual increase in the next 5 years.
Other-Recruiting costs-for recruiting services, DMV reports, LiveScan, TB and drug testing. Year 1 is$6,970 for initial
recruitment of staff and reduced to$3,269-$3,580 for years 2-6.
Other-Property taxes, business licenses-$1,600-$2,676 for local property taxes and business licenses. Budget
includes 2%-3% annual increase in the next 4 years.
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 137,969 $ 220,908 $ 225,200 $ 228,388 $ 235,998 $ 243,078
Financial Services Expenses-Line Items 1080-1085
Accounting/Bookkeeping-$17,100-$19,823 for approximately 40 hours per month for staff accountant. Budget
includes 3% annual increase in the next 5 years.
External Audit-$6,000-$6,821 for annual external audit fees. Budget includes 2%-3%annual increase in the next 5
years.
Liability Insurance-$9,471 -$10,559 based on $416.30 per FTE for all insurances including property, auto, business,
cyber and umbrella coverage. Budget includes 2%-3%annual increase in the next 5 years.
Administrative Overhead -$207,847-$344,295 This is includes Centralize Administrative Services and Centralize Fiscal
Service. Centralize Administrative Services is an allocation from Stars Behavioral Health Group of operations
administration, information technology, human resources, communications, finance, and associated fringe benefits and
expenses. Centralize Fiscal Service represents operating income for Central Star. As a profit provider, Central Star has no
ability to do fund raising to offset overhead costs such as income taxes, interest expense, and other unreimbursed
expenses. This provides a cushion to mitigate this exposure. Administrative centralize services and Fiscal centralize
services are 7%- 10%and 3%-5% respectively. Both these overhead costs are based on a percentage of total program
costs less Flex fund, Centralize Program Services, Centralize Administrative centralize services and Fiscal centralize
services.
Payroll Services-for payroll processing for Year 1 based on $23.50 per FTE per month ($6,204). Changing payroll
processor in Year 2 for cost saving ($2,640). Budget includes 3% annual increase in the next 4 years.
Professional Liability Insurance-all insurance costs are included above
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 166,415 $ 301,780 $ 326,964 $ 356,573 $ 373,271 $ 384,469
Special Expenses-Line Items 1090-1092
Translation Services-$800-$1,377 based on$100 per month. Budget includes 2%-3%annual increase in the next 5
years.
Exhibit E
Page 4 of 22
Medication Supports-$149,760-$251,805 for psychiatrist medication support services. Cost based on $240 per hour
for 18 hours per week which is for 30 minutes per client per month. Budget includes 2%-3%annual increase in the next 5
years.
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 150,560 $ 230,369 $ 234,988 $ 237,352 $ 244,471 $ 251,805
Fixed Assets—Line Items 1190-1193
Other-Van depreciation totaling $30,000 for 6 years.
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 4,000 $ 6,000 $ 6,000 $ 6,000 $ 6,000 $ 2,000
Non-Medi-Cal Client Support Expenses—Line Items 2000-2002.8
Funds for clients-$183,337-$300,000-Year 1 $183,337 less during ramp up. Years 2-6$300,000 per year.
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 183,337 $ 300,000 $ 300,000 $ 300,000 $ 300,000 $ 300,000
TOTAL PROGRAM EXPENSE:
FY 18/19 FY 19/20 FY 20/21 FY 21/22 FY 22/23 FY 23/24
$ 1,779,888 $ 2,670,548 $ 2,761,408 $ 2,843,832 $ 2,929,036 $ 3,003,727
Exhibit E
Page 5 of 22
County of Fresno -Transitioned Age Youth (TAY) Services - Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY 2018-2019 (Nov. 1, 2018 -Jun. 30, 2019)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized) FTE % Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Director 1.00 $60,000 $60,000
0002 Mental Health professionals -supervisors 2.00 $109,333 $109,333
0003 Mental Health Specialists 5.00 $174,167 $174,167
0004 Personal Service coordinators 7.00 $172,667 $172,667
0005 Housing and Employment Resource Specialist 1.00 $28,000 $28,000
0006 Peer Specialist 1.00 $22,667 $22,667
0007 Family Partner 1.00 $22,667 $22,667
0008 LVN 2.50 $81,667 $81,667
0009 Receptionist/Clerk 1.00 $20,800 $20,800
0010 Billing Clerk 0.50 $11,856 $11,856
0011 Training Coordinator 0.25 $8,667 $8,667
0012 QA Coordinator 0.25 $11,333 $11,333
0013 HR Coordinator 0.25 $8,333 $8,333
SALARY TOTAL 22.75 $120,989 $611,167 $732,156
PAYROLL TAXES:
0030 OASDI $7,501 $37,892 $45,394
0031 FICA/MEDICARE $1,754 $8,862 $10,616
0032 SUI $2,843 $14,362 $17,206
PAYROLL TAX TOTAL $12,099 $61,117 $73,216
EMPLOYEE BENEFITS:
0040 Retirement $2,647 $13,369 $16,016
0041 Workers Compensation $3,630 $18,335 $21,965
0042 Health Insurance (medical, vision, life, dental) 1 $12,855 $64,936 $77,792
EMPLOYEE BENEFITS TOTAL $19,131 $96,641 $115,772
SALARY& BENEFITS GRAND TOTAL $921,144
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $66,000
1011 Rent/Lease Equipment $8,000
1012 Utilities $7,667
1013 Building Maintenance $12,667
1014 Equipment purchase $122,130
FACILITY/EQUIPMENT TOTAL $216,463
OPERATING EXPENSES:
1060 Telephone $24,587
1061 Answering Service $0
1062 Postage $600
Exhibit E
Page 6 of 22
1063 Printing/Reproduction $0
1064 Publications $800
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $8,610
1067 Household Supplies $0
1068 Food $1,600
1069 Program Supplies-Therapeutic $5,333
1070 Program Supplies- Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $31,423
1073 Staff Travel (Out of County) $2,333
1074 Staff Training/Registration $4,800
1075 Lodging $0
1076 Other- Program services $27,713
1077 Other- Drug testing $21,600
1078 Other- Recruiting $6,970
1079 Other- Property taxes, business licenses $1,600
OPERATING EXPENSES TOTAL $137,969
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $11,400
1081 External Audit $6,000
1082 Liability Insurance $6,314
1083 Administrative Overhead $138,565
1084 Payroll Services $4,136
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $166,415
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $800
1092 Medication Supports $149,760
SPECIAL EXPENSES TOTAL $150,560
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other-depreciation for 1 Van $4,000
1193 Other- (Identify) $0
FIXED ASSETS TOTAL $4,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $83,333
2001 Client Housing Operating Expenditures (SFC 71) $33,333
2002.1 Clothing, Food & Hygiene (SFC 72) $13,334
2002.2 Client Transportation & Support(SFC 72) $10,000
Exhibit E
Page 7 of 22
2002.3 Education Support (SFC 72) $13,334
2002.4 Employment Support (SFC 72) $13,334
2002.5 Respite Care (SFC 72) $3,334
2002.6 Household Items $6,667
2002.7 Utility Vouchers (SFC 72) $3,334
L!t
Child Care SFC 72 $3,334
NON MEDI-CAL CLIENT SUPPORT TOTAL $183,337
TOTAL PROGRAM EXPENSES $1,779,888
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services (Individual/Family/Group Therapy) 191,063 $2.87 $548,352
3100 Case Management 92,679 $2.21 $204,822
3200 Crisis Services 4,971 $4.17 $20,730
3300 Medication Support 24,570 $5.28 $129,730
3400 Collateral 44,574 $2.87 $127,926
3500 Plan Development 14,858 $2.87 $42,643
3600 Assessment 14,858 $2.87 $42,643
3700 Rehabilitation 92,863 $2.87 $266,516
3800 ICC 10,297 $2.21 $22,756
3900 IHBS 18,573 $2.87 $53,304
Estimated Specialty Mental Health Services Billing Totalsl 509,306 $1,459,420
Estimated % of Clients that are Medi-Cal Beneficiaries 84.0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $1,225,913
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00% $612,957
State M/Cal Share of Cost % (BH Real ignment/EPSDT) 50.00% $612,957
MEDI-CAL REVENUE TOTAL $1,225,913
OTHER REVENUE:
4000 Non Medi-Cal eligible/Private Insurance $6,667
4100 Other- (Identify) $0
OTHER REVENUE TOTAL: MHSA Funds $6,667
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $0
5100 Community Services & Supports (CSS) Funds (Includes one time ramp cost of$127,130) $547,308
5200 Innovation (INN) Funds $0
5300 Workforce Education &Training (WET) Funds $0
MHSA FUNDS TOTAL $547,308
TOTAL PROGRAM REVENUE $1,779,888
Exhibit E
Page 8 of 22
County of Fresno -Transitioned Age Youth (TAY) Services - Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY 2019-2020
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized) FTE % Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Director 1.00 $92,700 $92,700
0002 Mental Health professionals -supervisors 2.00 $168,920 $168,920
0003 Mental Health Specialists 5.00 $269,088 $269,088
0004 Personal Service coordinators 7.00 $266,770 $266,770
0005 Housing and Employment Resource Specialist 1.00 $43,260 $43,260
0006 Peer Specialist 1.00 $35,360 $35,360
0007 Family Partner 1.00 $35,360 $35,360
0008 LVN 2.50 $127,400 $127,400
0009 Receptionist/Clerk 1.00 $32,448 $32,448
0010 Billing Clerk 0.50 $18,495 $18,495
0011 Training Coordinator 0.25 $13,520 $13,520
0012 QA Coordinator 0.25 $17,680 $17,680
0013 HR Coordinator 0.25 $13,000 $13,000
SALARY TOTAL 22.75 $187,843 $946,158 $1,134,001
PAYROLL TAXES:
0030 OASDI $11,646 $58,662 $70,308
0031 FICA/MEDICARE $2,724 $13,719 $16,443
0032 SUI $4,414 $22,235 $26,649
PAYROLL TAX TOTAL $18,784 $94,616 $113,400
EMPLOYEE BENEFITS:
0040 Retirement $4,226 $21,289 $25,515
0041 Workers Compensation $5,635 $28,385 $34,020
0042 Health Insurance (medical, vision, life, dental) 1 $23,480 $118,270 $141,750
EMPLOYEE BENEFITS TOTAL $33,342 $167,943 $201,285
SALARY& BENEFITS GRAND TOTAL $1,448,686
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $99,990
1011 Rent/Lease Equipment $12,000
1012 Utilities $11,615
1013 Building Maintenance $12,000
1014 Equipment purchase $27,200
FACILITY/EQUIPMENT TOTAL $162,805
OPERATING EXPENSES:
1060 Telephone $36,880
1061 Answering Service $0
1062 Postage $927
Exhibit E
Page 9 of 22
1063 Printing/Reproduction $0
1064 Publications $1,236
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $11,282
1067 Household Supplies $0
1068 Food $2,472
1069 Program Supplies-Therapeutic $8,240
1070 Program Supplies- Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $48,902
1073 Staff Travel (Out of County) $3,500
1074 Staff Training/Registration $7,416
1075 Lodging $0
1076 Other- Program services $61,312
1077 Other- Drug testing $33,048
1078 Other- Recruiting $3,269
1079 Other- Property taxes, business licenses $2,424
OPERATING EXPENSES TOTAL $220,908
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $17,613
1081 External Audit $6,180
1082 Liability Insurance $9,660
1083 Administrative Overhead $265,687
1084 Payroll Services $2,640
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $301,780
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $1,236
1092 Medication Supports $229,133
SPECIAL EXPENSES TOTAL $230,369
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other-depreciation for 1 Van $6,000
1193 Other- (Identify) $0
FIXED ASSETS TOTAL $6,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $135,000
2001 Client Housing Operating Expenditures (SFC 71) $54,000
2002.1 Clothing, Food & Hygiene (SFC 72) $22,000
2002.2 Client Transportation & Support(SFC 72) $17,000
Exhibit E
Page 10 of 22
2002.3 Education Support (SFC 72) $22,000
2002.4 Employment Support (SFC 72) $22,000
2002.5 Respite Care (SFC 72) $5,500
2002.6 Household Items $11,500
2002.7 Utility Vouchers (SFC 72) $5,500
2002.8 Child Care (SFC 72) $5,500
NON MEDI-CAL CLIENT SUPPORT TOTAL $300,000
TOTAL PROGRAM EXPENSES $2,670,548
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services (Individual/Family/Group Therapy) 316,997 $2.87 $909,783
3100 Case Management 155,752 $2.21 $344,211
3200 Crisis Services 8,530 $4.17 $35,569
3300 Medication Support 38,602 $5.44 $209,936
3400 Collateral 76,079 $2.87 $218,348
3500 Plan Development 22,336 $2.87 $64,106
3600 Assessment 22,336 $2.87 $64,106
3700 Rehabilitation 139,607 $2.87 $400,671
3800 ICC 15,244 $2.21 $33,689
3900 IHBS 27,920 $2.87 $80,131
Estimated Specialty Mental Health Services Billing Totals 823,404 $2,360,548
Estimated % of Clients that are Medi-Cal Beneficiaries 84.0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $1,982,861
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00% $991,430
State M/Cal Share of Cost % (BH Real ignment/EPSDT) 50.00% $991,430
MEDI-CAL REVENUE TOTAL $1,982,861
OTHER REVENUE:
4000 Non Medi-Cal eligible/Private Insurance $10,000
4100 Other- (Identify) $0
OTHER REVENUE TOTAL: MHSA Funds $10,000
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $0
5100 Community Services & Supports (CSS) Funds $677,688
5200 Innovation (INN) Funds $0
5300 Workforce Education &Training (WET) Funds $0
MHSA FUNDS TOTAL $677,688
TOTAL PROGRAM REVENUE $2,670,549
Exhibit E
Page 11 of 22
County of Fresno -Transitioned Age Youth (TAY) Services - Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY 2020-2021
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized) FTE % Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Director 1.00 $96,408 $96,408
0002 Mental Health professionals -supervisors 2.00 $175,677 $175,677
0003 Mental Health Specialists 5.00 $279,851 $279,851
0004 Personal Service coordinators 7.00 $277,441 $277,441
0005 Housing and Employment Resource Specialist 1.00 $44,990 $44,990
0006 Peer Specialist 1.00 $36,421 $36,421
0007 Family Partner 1.00 $36,421 $36,421
0008 LVN 2.50 $131,222 $131,222
0009 Receptionist/Clerk 1.00 $33,421 $33,421
0010 Billing Clerk 0.50 $19,050 $19,050
0011 Training Coordinator 0.25 $13,926 $13,926
0012 QA Coordinator 0.25 $18,210 $18,210
0013 HR Coordinator 0.25 $13,390 $13,390
SALARY TOTAL 22.75 $194,405 $982,023 $1,176,428
PAYROLL TAXES:
0030 OASDI $12,053 $60,885 $72,939
0031 FICA/MEDICARE $2,819 $14,239 $17,058
0032 SUI $4,569 $23,078 $27,646
PAYROLL TAX TOTAL $19,441 $98,202 $117,643
EMPLOYEE BENEFITS:
0040 Retirement $4,374 $22,096 $26,470
0041 Workers Compensation $5,832 $29,461 $35,293
0042 Health Insurance (medical, vision, life, dental) 1 $24,3011 $122,753 $147,054
EMPLOYEE BENEFITS TOTAL $34,5071 $174,309 $208,816
SALARY& BENEFITS GRAND TOTAL $1,502,887
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $101,490
1011 Rent/Lease Equipment $12,000
1012 Utilities $11,963
1013 Building Maintenance $12,360
1014 Equipment purchase $27,556
FACILITY/EQUIPMENT TOTAL $165,369
OPERATING EXPENSES:
1060 Telephone $36,880
1061 Answering Service $0
1062 Postage $955
Exhibit E
Page 12 of 22
1063 Printing/Reproduction $0
1064 Publications $1,273
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $11,607
1067 Household Supplies $0
1068 Food $2,546
1069 Program Supplies-Therapeutic $8,487
1070 Program Supplies- Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $49,577
1073 Staff Travel (Out of County) $3,500
1074 Staff Training/Registration $7,638
1075 Lodging $0
1076 Other- Program services $63,248
1077 Other- Drug testing $33,709
1078 Other- Recruiting $3,308
1079 Other- Property taxes, business licenses $2,472
OPERATING EXPENSES TOTAL $225,200
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $18,141
1081 External Audit $6,365
1082 Liability Insurance $9,853
1083 Administrative Overhead $289,886
1084 Payroll Services $2,719
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $326,964
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $1,273
1092 Medication Supports $233,715
SPECIAL EXPENSES TOTAL $234,988
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other-depreciation for 1 Van $6,000
1193 Other- (Identify) $0
FIXED ASSETS TOTAL $6,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $135,000
2001 Client Housing Operating Expenditures (SFC 71) $54,000
2002.1 Clothing, Food & Hygiene (SFC 72) $22,000
2002.2 Client Transportation & Support(SFC 72) $17,000
Exhibit E
Page 13 of 22
2002.3 Education Support (SFC 72) $22,000
2002.4 Employment Support (SFC 72) $22,000
2002.5 Respite Care (SFC 72) $5,500
2002.6 Household Items $11,500
2002.7 Utility Vouchers (SFC 72) $5,500
2002.8 Child Care (SFC 72) $5,500
NON MEDI-CAL CLIENT SUPPORT TOTAL $300,000
TOTAL PROGRAM EXPENSES $2,761,408
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services (Individual/Family/Group Therapy) 307,054 $2.96 $908,879
3100 Case Management 150,866 $2.32 $350,009
3200 Crisis Services 8,262 $4.28 $35,362
3300 Medication Support 37,392 $5.60 $209,393
3400 Collateral 73,693 $2.96 $218,131
3500 Plan Development 24,564 $2.96 $72,709
3600 Assessment 24,564 $2.96 $72,709
3700 Rehabilitation 153,527 $2.96 $454,441
3800 ICC 16,764 $2.32 $38,893
3900 IHBS 30,704 $2.96 $90,884
Estimated Specialty Mental Health Services Billing Totals 827,389 $2,451,408
Estimated % of Clients that are Medi-Cal Beneficiaries 84.0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $2,059,183
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00% $1,029,592
State M/Cal Share of Cost % (BH Real ignment/EPSDT) 50.00% $1,029,592
MEDI-CAL REVENUE TOTAL $2,059,183
OTHER REVENUE:
4000 Non Medi-Cal eligible/Private Insurance $10,000
4100 Other- (Identify) $0
OTHER REVENUE TOTAL: MHSA Funds $10,000
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $0
5100 Community Services & Supports (CSS) Funds $692,225
5200 Innovation (INN) Funds $0
5300 Workforce Education &Training (WET) Funds $0
MHSA FUNDS TOTAL $692,225
TOTAL PROGRAM REVENUE $2,761,408
Exhibit E
Page 14 of 22
County of Fresno -Transitioned Age Youth (TAY) Services - Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY 2021-2022
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized) FTE % Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Director 1.00 $99,300 $99,300
0002 Mental Health professionals -supervisors 2.00 $180,947 $180,947
0003 Mental Health Specialists 5.00 $288,247 $288,247
0004 Personal Service coordinators 7.00 $285,764 $285,764
0005 Housing and Employment Resource Specialist 1.00 $46,340 $46,340
0006 Peer Specialist 1.00 $37,513 $37,513
0007 Family Partner 1.00 $37,513 $37,513
0008 LVN 2.50 $135,158 $135,158
0009 Receptionist/Clerk 1.00 $34,424 $34,424
0010 Billing Clerk 0.50 $19,622 $19,622
0011 Training Coordinator 0.25 $14,343 $14,343
0012 QA Coordinator 0.25 $18,757 $18,757
0013 HR Coordinator 0.25 $13,792 $13,792
SALARY TOTAL 22.75 $200,238 $1,011,482 $1,211,720
PAYROLL TAXES:
0030 OASDI $12,415 $62,712 $75,127
0031 FICA/MEDICARE $2,903 $14,666 $17,570
0032 SUI $4,706 $23,770 $28,475
PAYROLL TAX TOTAL $20,024 $101,148 $121,172
EMPLOYEE BENEFITS:
0040 Retirement $4,505 $22,758 $27,264
0041 Workers Compensation $6,007 $30,344 $36,352
0042 Health Insurance (medical, vision, life, dental) 1 $25,030 $126,435 $151,465
EMPLOYEE BENEFITS TOTAL $35,542 $179,538 $215,080
SALARY& BENEFITS GRAND TOTAL $1,547,972
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $102,505
1011 Rent/Lease Equipment $12,120
1012 Utilities $12,322
1013 Building Maintenance $12,484
1014 Equipment purchase $28,116
FACILITY/EQUIPMENT TOTAL $167,547
OPERATING EXPENSES:
1060 Telephone $36,880
1061 Answering Service $0
1062 Postage $974
Exhibit E
Page 15 of 22
1063 Printing/Reproduction $0
1064 Publications $1,299
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $11,422
1067 Household Supplies $0
1068 Food $2,597
1069 Program Supplies-Therapeutic $8,657
1070 Program Supplies- Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $50,168
1073 Staff Travel (Out of County) $3,500
1074 Staff Training/Registration $7,791
1075 Lodging $0
1076 Other- Program services $64,821
1077 Other- Drug testing $34,383
1078 Other- Recruiting $3,374
1079 Other- Property taxes, business licenses $2,522
OPERATING EXPENSES TOTAL $228,388
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $18,686
1081 External Audit $6,429
1082 Liability Insurance $9,952
1083 Administrative Overhead $318,705
1084 Payroll Services $2,801
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $356,573
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $1,299
1092 Medication Supports $236,053
SPECIAL EXPENSES TOTAL $237,352
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other-depreciation for 1 Van $6,000
1193 Other- (Identify) $0
FIXED ASSETS TOTAL $6,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $135,000
2001 Client Housing Operating Expenditures (SFC 71) $54,000
2002.1 Clothing, Food & Hygiene (SFC 72) $22,000
2002.2 Client Transportation & Support(SFC 72) $17,000
Exhibit E
Page 16 of 22
2002.3 Education Support (SFC 72) $22,000
2002.4 Employment Support (SFC 72) $22,000
2002.5 Respite Care (SFC 72) $5,500
2002.6 Household Items $11,500
2002.7 Utility Vouchers (SFC 72) $5,500
2002.8 Child Care (SFC 72) $5,500
NON MEDI-CAL CLIENT SUPPORT TOTAL $300,000
TOTAL PROGRAM EXPENSES $2,843,832
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services (Individual/Family/Group Therapy) 308,179 $3.05 $939,946
3100 Case Management 151,419 $2.38 $360,377
3200 Crisis Services 8,292 $4.46 $36,984
3300 Medication Support 37,529 $5.77 $216,540
3400 Collateral 73,963 $3.05 $225,587
3500 Plan Development 24,654 $3.05 $75,194
3600 Assessment 24,654 $3.05 $75,194
3700 Rehabilitation 154,090 $3.05 $469,974
3800 ICC 16,825 $2.38 $40,045
3900 IHBS 30,817 $3.05 $93,991
Estimated Specialty Mental Health Services Billing Totals 830,422 $2,533,832
Estimated % of Clients that are Medi-Cal Beneficiaries 84.0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $2,128,419
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00% $1,064,210
State M/Cal Share of Cost % (BH Real ignment/EPSDT) 50.00% $1,064,210
MEDI-CAL REVENUE TOTAL $2,128,419
OTHER REVENUE:
4000 Non Medi-Cal eligible/Private Insurance $10,000
4100 Other- (Identify) $0
OTHER REVENUE TOTAL: MHSA Funds $10,000
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $0
5100 Community Services & Supports (CSS) Funds $705,413
5200 Innovation (INN) Funds $0
5300 Workforce Education &Training (WET) Funds $0
MHSA FUNDS TOTAL $705,413
TOTAL PROGRAM REVENUE $2,843,832
Exhibit E
Page 17 of 22
County of Fresno -Transitioned Age Youth (TAY) Services - Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY 2022-2023
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized) FTE % Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Director 1.00 $102,279 $102,279
0002 Mental Health professionals -supervisors 2.00 $186,376 $186,376
0003 Mental Health Specialists 5.00 $296,894 $296,894
0004 Personal Service coordinators 7.00 $294,337 $294,337
0005 Housing and Employment Resource Specialist 1.00 $47,730 $47,730
0006 Peer Specialist 1.00 $38,639 $38,639
0007 Family Partner 1.00 $38,639 $38,639
0008 LVN 2.50 $139,213 $139,213
0009 Receptionist/Clerk 1.00 $35,457 $35,457
0010 Billing Clerk 0.50 $20,210 $20,210
0011 Training Coordinator 0.25 $14,774 $14,774
0012 QA Coordinator 0.25 $19,319 $19,319
0013 HR Coordinator 0.25 $14,205 $14,205
SALARY TOTAL 22.75 $170,787 $1,077,285 $1,248,072
PAYROLL TAXES:
0030 OASDI $10,589 $66,792 $77,380
0031 FICA/MEDICARE $2,476 $15,621 $18,097
0032 SUI $4,013 $25,316 $29,330
PAYROLL TAX TOTAL $17,079 $107,729 $124,807
EMPLOYEE BENEFITS:
0040 Retirement $3,843 $24,239 $28,082
0041 Workers Compensation $5,124 $32,319 $37,442
0042 Health Insurance (medical, vision, life, dental) 1 $21,348 $134,661 $156,009
EMPLOYEE BENEFITS TOTAL $30,315 $191,218 $221,533
SALARY& BENEFITS GRAND TOTAL $1,594,412
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $105,580
1011 Rent/Lease Equipment $12,484
1012 Utilities $12,692
1013 Building Maintenance $13,919
1014 Equipment purchase $30,209
FACILITY/EQUIPMENT TOTAL $174,884
OPERATING EXPENSES:
1060 Telephone $37,987
1061 Answering Service $0
1062 Postage $1,003
Exhibit E
Page 18 of 22
1063 Printing/Reproduction $0
1064 Publications $1,337
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $12,539
1067 Household Supplies $0
1068 Food $2,675
1069 Program Supplies-Therapeutic $8,917
1070 Program Supplies- Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $51,673
1073 Staff Travel (Out of County) $3,500
1074 Staff Training/Registration $8,025
1075 Lodging $0
1076 Other- Program services $66,853
1077 Other- Drug testing $35,415
1078 Other- Recruiting $3,476
1079 Other- Property taxes, business licenses $2,598
OPERATING EXPENSES TOTAL $235,998
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $19,246
1081 External Audit $6,622
1082 Liability Insurance $10,251
1083 Administrative Overhead $334,267
1084 Payroll Services $2,885
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $373,271
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $1,337
1092 Medication Supports $243,134
SPECIAL EXPENSES TOTAL 1 $244,471
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other-depreciation for 1 Van $6,000
1193 Other- (Identify) $0
FIXED ASSETS TOTAL $6,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $135,000
2001 Client Housing Operating Expenditures (SFC 71) $54,000
2002.1 Clothing, Food & Hygiene (SFC 72) $22,000
2002.2 Client Transportation & Support(SFC 72) $17,000
Exhibit E
Page 19 of 22
2002.3 Education Support (SFC 72) $22,000
2002.4 Employment Support (SFC 72) $22,000
2002.5 Respite Care (SFC 72) $5,500
2002.6 Household Items $11,500
2002.7 Utility Vouchers (SFC 72) $5,500
2002.8 Child Care (SFC 72) $5,500
NON MEDI-CAL CLIENT SUPPORT TOTAL $300,000
TOTAL PROGRAM EXPENSES $2,929,036
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services (Individual/Family/Group Therapy) 309,276 $3.14 $971,126
3100 Case Management 151,958 $2.45 $372,296
3200 Crisis Services 8,322 $4.60 $38,281
3300 Medication Support 37,662 $5.97 $224,843
3400 Collateral 74,226 $3.14 $233,070
3500 Plan Development 24,741 $3.14 $77,688
3600 Assessment 24,741 $3.14 $77,688
3700 Rehabilitation 154,638 $3.14 $485,564
3800 ICC 16,885 $2.45 $41,369
3900 IHBS 30,926 $3.14 $97,109
Estimated Specialty Mental Health Services Billing Totals 833,377 $2,619,036
Estimated % of Clients that are Medi-Cal Beneficiaries 84.0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $2,199,990
Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 50.00% $1,099,995
State M/Cal Share of Cost % (BH Real ignment/EPSDT) 50.00% $1,099,995
MEDI-CAL REVENUE TOTAL $2,199,990
OTHER REVENUE:
4000 Non Medi-Cal eligible/Private Insurance $10,000
4100 Other- (Identify) $0
OTHER REVENUE TOTAL: MHSA Funds $10,000
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $0
5100 Community Services & Supports (CSS) Funds $719,046
5200 Innovation (INN) Funds $0
5300 Workforce Education &Training (WET) Funds $0
MHSA FUNDS TOTAL $719,046
TOTAL PROGRAM REVENUE $2,929,036
Exhibit E
Page 20 of 22
County of Fresno -Transitioned Age Youth (TAY) Services - Full Service Partnership (FSP) RFP 18-038
Central Star Behavioral Health
FY 2023-2024
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized) FTE % Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Director 1.00 $105,347 $105,347
0002 Mental Health professionals -supervisors 2.00 $191,967 $191,967
0003 Mental Health Specialists 5.00 $305,801 $305,801
0004 Personal Service coordinators 7.00 $303,167 $303,167
0005 Housing and Employment Resource Specialist 1.00 $49,162 $49,162
0006 Peer Specialist 1.00 $39,798 $39,798
0007 Family Partner 1.00 $39,798 $39,798
0008 LVN 2.50 $143,389 $143,389
0009 Receptionist/Clerk 1.00 $36,521 $36,521
0010 Billing Clerk 0.50 $20,816 $20,816
0011 Training Coordinator 0.25 $15,217 $15,217
0012 QA Coordinator 0.25 $19,899 $19,899
0013 HR Coordinator 0.25 $14,631 $14,631
SALARY TOTAL 22.75 $175,911 $1,109,604 $1,285,514
PAYROLL TAXES:
0030 OASDI $10,906 $68,795 $79,702
0031 FICA/MEDICARE $2,551 $16,089 $18,640
0032 SUI $4,134 $26,076 $30,210
PAYROLL TAX TOTAL $17,591 $110,960 $128,551
EMPLOYEE BENEFITS:
0040 Retirement $3,958 $24,966 $28,924
0041 Workers Compensation $5,277 $33,288 $38,565
0042 Health Insurance (medical, vision, life, dental) $21,989 $138,700 $160,689
EMPLOYEE BENEFITS TOTAL $31,224 $196,955 $228,179
SALARY & BENEFITS GRAND TOTAL $1,642,244
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $108,747
1011 Rent/Lease Equipment $12,859
1012 Utilities $13,073
1013 Building Maintenance $14,337
1014 Equipment purchase 1 $31,115
FACILITY/EQUIPMENT TOTAL 1 $180,131
OPERATING EXPENSES:
1060 Telephone $39,127
1061 Answering Service $0
Exhibit E
Page 21 of 22
1062 Postage $1,033
1063 Printing/Reproduction $0
1064 Publications $1,377
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $12,915
1067 Household Supplies $0
1068 Food $2,755
1069 Program Supplies -Therapeutic $9,185
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $53,223
1073 Staff Travel (Out of County) $3,605
1074 Staff Training/Registration $8,266
1075 Lodging $0
1076 Other- Program services $68,859
1077 Other- Drug testing $36,477
1078 Other- Recruiting $3,580
1079 Other- Property taxes, business licenses $2,676
OPERATING EXPENSES TOTAL $243,078
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $19,823
1081 External Audit $6,821
1082 Liability Insurance $10,559
1083 Administrative Overhead $344,295
1084 Payroll Services $2,972
1085 Professional Liability Insurance $0
FINANCIAL SERVICES TOTAL $384,469
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) $0
1091 Translation Services $1,377
1092 Medication Supports $250,428
SPECIAL EXPENSES TOTAL 1 $251,805
FIXED ASSETS:
1190 Computers & Software $0
1191 Furniture & Fixtures $0
1192 Other-depreciation for 1 Van $2,000
1193 Other- (Identify) $0
FIXED ASSETS TOTAL $2,000
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70) $135,000
2001 Client Housing Operating Expenditures (SFC 71) $54,000
2002.1 Clothing, Food & Hygiene (SFC 72) $22,000
Exhibit G
Page 22 of 22
2002.2 Client Transportation & Support (SFC 72) $17,000
2002.3 Education Support (SFC 72) $22,000
2002.4 Employment Support (SFC 72) $22,000
2002.5 Respite Care (SFC 72) $5,500
2002.6 Household Items $11,500
2002.7 Utility Vouchers (SFC 72) $5,500
2002.8 Child Care (SFC 72) $5,500
NON MEDI-CAL CLIENT SUPPORT TOTAL $300,000
TOTAL PROGRAM EXPENSES $3,003,727
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services (Individual/Family/Group Therapy) 318,096 $3.14 $998,821
3100 Case Management 156,291 $2.45 $382,914
3200 Crisis Services 8,559 $4.60 $39,373
3300 Medication Support 38,736 $5.97 $231,255
3400 Collateral 76,343 $3.14 $239,717
3500 Plan Development 25,447 $3.14 $79,904
3600 Assessment 25,447 $3.14 $79,904
3700 Rehabilitation 159,048 $3.14 $499,412
3800 ICC 17,367 $2.45 $42,549
3900 IHBS 31,808 $3.14 $99,878
Estimated Specialty Mental Health Services Billing Totals 857,144 "w $2,693,727
Estimated % of Clients that are Medi-Cal Beneficiaries 84.0%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $2,262,731
Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 50.00% $1,131,365
State M/Cal Share of Cost % (BH Realignment/EPSDT) 50.00% $1,131,365
MEDI-CAL REVENUE TOTAL $2,262,731
OTHER REVENUE:
4000 Non Medi-Cal eligible/Private Insurance $10,000
4100 Other- (Identify) $0
OTHER REVENUE TOTAL: MHSA Funds $10,000
MENTAL HEALTH SERVICES ACT (MHSA) REVENUE:
5000 Prevention & Early Intervention (PEI) Funds $0
5100 Community Services & Supports (CSS) Funds $730,996
5200 Innovation (INN) Funds $0
5300 Workforce Education &Training (WET) Funds $0
MHSA FUNDS TOTAL $730,996
TOTAL PROGRAM REVENUE $3,003,727
Exhibit F
Fresno County Mental Health Plan
Compliance Program
Policy and Procedure
Subject: Code of Conduct
Effective Date: August 1, 2004
Revision Date: July 9, 2010
POLICY:
Fresno County is firmly committed to full compliance with all applicable laws, regulations, rules, and
guidelines that apply to its mental health operations and services. At the core of this commitment are
Fresno County's employees, contractors (including contractor's employees/subcontractors), volunteers
and students, also referred to as "Covered Persons", and the manner in which they conduct
themselves. To assure that Fresno County's commitment is shared by all Covered Persons, this Code
of Conduct (the "Code") has been established. All Covered Persons will be required to acknowledge
and certify their compliance to this Code.
PURPOSE:
To provide specific conduct standards prescribed by the Fresno County Mental Health Plan
Compliance Program. This Code of Conduct is maintained in addition to the County's Code of Ethics
already in effect.
DEFINITIONS:
Covered Persons—All employees, contractors (including contractor's employees and subcontractors),
volunteers and students working in behavioral/mental health programs.
Excluded Person —Any Covered Person who is or may become suspended, excluded, or ineligible from
participation in any Federal healthcare program.
PROCEDURE:
1. A copy of the Code of Conduct (see Attachment A)will be provided to all Covered Persons at the
time of their initial compliance training which must be provided within 30 business days of hire or
contract effective date. This Code will also be provided during the annual General Compliance
training or within 30 business days after any revision is finalized.
2. Upon initial receipt and review of the Code, Covered Persons shall certify their intention to abide by
it by signing the Acknowledgement and Agreement form (see Attachment B for sample form).
These signed forms will be retained by the Compliance Office. Covered Persons shall certify within
30 business days after distribution of a revised Code.
3. The Compliance Office will track these certifications and regularly report to the Compliance
Committee and the Directors of the Departments of Behavioral Health and Public Health regarding
progress towards 100% certification by all Covered Persons.
4. The Code will be prominently posted in all Fresno County and contractor mental health facilities
and sites.
5. This Code is not intended to be an exhaustive list of all standards by which Covered Persons are
to be governed. Rather, it is intended to convey the County's commitment to the high standards set
forth by the County.
Exhibit F
Fresno County Mental Health Plan — (Attachment A)
Compliance Program
CODE OF CONDUCT:
All Fresno County Behavioral/Mental Health Employees, Contractors (including Contractor's
Employees/Subcontractors), Volunteers and Students will:
1. Read, acknowledge, and abide by this Code of Conduct.
2. Be responsible for reviewing and understanding Compliance Program policies and procedures
including the possible consequences for failure to comply or failure to report such non-
compliance.
3. 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. Conduct yourself
honestly, fairly, courteously, and with a high degree of integrity in your professional dealings
related to their employment/contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County and the services it
provides.
4. Practice good faith in transactions occurring during the course of business and never use or
exploit professional relationships or confidential information for personal purposes.
5. Promptly report any activity or suspected violation of this Code of Conduct, the policies and
procedures of the County, the Compliance Program, or any other applicable law, regulation, rule
or guideline. All reports may be made anonymously. 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.
6. Comply with not only the letter of Compliance Program and mental health policies and
procedures, but also with the spirit of those policies and procedures as well as other rules or
guidelines adopted by the County. Consult with your supervisor or the Compliance Office
regarding any Compliance Program standard or other applicable law, regulation, rule or
guideline.
7. Comply with all laws governing the confidentiality and privacy of information. Protect and retain
records and documents as required by County contract/standards, professional standards,
governmental regulations, or organizational policies.
8. Comply with all applicable laws, regulations, rules, guidelines, and County policies and
procedures when providing and billing mental health services. Bill only for eligible services
actually rendered and fully documented. Use billing codes that accurately describe the services
provided. Ensure that no false, fraudulent, inaccurate, or fictitious claims for payment or
reimbursement of any kind are prepared or submitted. Ensure that claims are prepared and
submitted accurately and timely and are consistent with all applicable laws, regulations, rules
and guidelines. Act promptly to investigate and correct problems if errors in claims or billings are
discovered.
9. Immediately notify your supervisor, Department Head, Administrator, or the Compliance Office if
you become or may become an Ineligible/Excluded Person and therefore excluded from
participation in the Federal health care programs.
Revised: 7/9/10
Exhibit F
FRESNO COUNTY MENTAL HEALTH PLAN
COMPLIANCE PROGRAM
Acknowledgment and Agreement — (Attachment B)
I hereby acknowledge that I have received, read and understand Fresno County's Code of Conduct,
Code of Ethics (County employees only), and have received training and information on the
Compliance Program and understand the contents thereof. I further acknowledge that I have received,
read and understand the Compliance Program policy titled "Prevention, Detection, and Correction of
Fraud, Waste and Abuse". I agree to abide by the Code of Conduct, Code of Ethics (County employees
only) and all Compliance Program requirements as they apply to my responsibilities as a County
employee, contractor/subcontractor, volunteer or student.
I understand and accept my responsibilities under this Acknowledgment and Agreement and
understand that any violation of the Code of Conduct, Code of Ethics (County employees only), or the
Compliance Program is a violation of County policy and may also be a violation of applicable laws,
regulations, rules or guidelines. I further understand that violation of these policies can result in
disciplinary action, up to and including termination of my employment or contractual agreement with the
County.
County Employees Only — Complete this Section
Full Name (printed):
Job Title:
Discipline (for licensed staff only): []Psychiatrist [ ]Psychologist []LCSW [ ]LMFT [ ]NP [ ]RN [ ]LVN [ ] LPT
Department: DBH: [] Adult MH [ ] Children MH [ ] Business Office/ISD [ ] Managed Care [ ] MHSA
[ ] Public Health [ ] Other:
Cost Center# Program Name:
Supervisor Name:
Employee Signature: Date:—/
Phone:
Contractors/Contractor Staff, Volunteers, Students only— Complete this Section
Agency Name (If applicable):
Full Name (Printed):
Discipline (Indicate below if applicable):
Licensed: [ ] Psychiatrist [ ] Psychologist [ ] LCSW [ ] LMFT
Unlicensed: [ ] Psychologist [] ASW [] IMF
Other
Job Title (If different from Discipline):
Signature: Date: / /
Phone:
New Emp/Contr Ack Rev: 7/9/10
Exhibit G
Page 1 of 3
Documentation Standards for Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics. All medical records shall be
maintained for a minimum of 10 years from the date of the end of the Agreement.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
• Presenting problems and relevant conditions affecting the client's physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
• Documentation will describe client's strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as
well as illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented,
consistent with the presenting problems, history mental status evaluation and/or other
assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in
the client's condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B. Client Plans
Exhibit G
Page 2 of 3
1.Client plans will:
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed(or electronic equivalent)by:
➢ the person providing the service(s), or
➢ a person representing a team or program providing services, or
➢ a person representing the MHP providing services
➢ when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
➢ a physician
➢ a licensed/"waivered"psychologist
➢ a licensed/"associate" social worker
➢ a licensed/registered/marriage and family therapist or
➢ a registered nurse
• In addition,
➢ client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client's
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to, reference to the client's participation and agreement in the body
of the plan, client signature on the plan, or a description of the client's participation
and agreement in progress notes.
➢ client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
➢ when the client's signature is required on the client plan and the client refuses or is
unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2.Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C. Progress Notes
1.Items that must be contained in the client record related to the client's progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
Exhibit G
Page 3 of 3
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person's professional degree, licensure or job title;
and the relevant identification number, if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care, or as appropriate, a discharge summary
2.Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A.Every Service Contact
• Mental Health Services
• Medication Support Services
• Crisis Intervention
EXHIBIT H
coU�� - Department of Behavioral Health
Policy and Procedure Guide
p� 60 ._
FRES PPG 1.2.7
Section: Administration
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
1 1 P a g e
EXHIBIT H
� ti COUP, Department of Behavioral Health
i Policy and Procedure Guide
o� 18s�0
FRE Section:Administration 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 H
co ( Department of Behavioral Health
Policy and Procedure Guide
f 1560 f
FR$ Section:Administration 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)
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FRESNO COUNTY MENTAL HEALTH PLAN EXHIBIT H
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 anall1sl s (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 I
Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level)persons employed by the COUNTY Mental Health
Program(directly or through contract)providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eli ig bility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall,because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination,upgrading, demotion, transfer,
Exhibit I
Page 2 of 6
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds,until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY's Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients'rights.
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 the proposed Agreement will:
1)receive a copy of the company's drug-free workplace policy statement; and,
Exhibit I
Page 3 of 6
2) agree to abide by the terms of the company's statement as a condition of employment
on the Agreement.
Failure to comply with these requirements may result in suspension of payments under
the Agreement or termination of the 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-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
Exhibit I
Page 4 of 6
penal sanction, abusive forms of child labor or exploitation of children in sweatshop
labor. The contractor further declares under penalty of perjury that they adhere to the
Sweatfree Code of Conduct as set forth on the California Department of Industrial
Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The 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 the Agreement, the awarding
agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). 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.
2). 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):
1). For the two-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.
2). For the twelve-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
Exhibit I
Page 5 of 6
employed by that state agency in a policy-making position in the same general subject
area as the proposed contract within the 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.
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
Exhibit I
Page 6 of 6
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 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 J
Page 1 of 2
FRESNO COUNTY MENTAL HEALTH PLAN
INCIDENT REPORTING
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident or first
knowledge of the incident:
• Incident Report should be sent to:
DBHincidentreportinq((�)fresnocountVca.gov and designated Contract Analyst
Exhibit J
Page 2 of 2
Fresno County Department of Behavioral Health-Incident Report
Send completed forms to dbhincidentreportingPfresnocountvca.goy and designated contract analyst within 24 hours of an
incident or knowledge of an incident. DO NOT COPY OR REPRODUCE/NOT part of the medical record.
Client Information
Last Name:Click or tap here to enter text. First Name:Click or tap here to enter text. Middle Initial:Click or tap here to enter text.
Date of Birth:Click or tap here to enter text.Client ID#:Click or tap here to enter text. Gender: ❑ Male ❑ Female
County of Origin: Click or tap here to enter text.
Name of Reporting Party:Click or tap here to enter text. Name of Facility:Click or tap here to enter text.
Facility Address:Click or tap here to enter text. Facility Phone Number:Click or tap here to enter text.
Incident(check all that apply)
❑ Homicide/Homicide Attempt ❑ Attempted Suicide(resulting in serious injury) ❑ Death of Client ❑ Medical Emergency
❑ Injury (self-inflicted or by accident) ❑ Violence/Abuse/Attempts to Assault(toward others,client and/or property)
❑ Other- Specify(i.e. medication errors,client escaping from locked facility, fire, poisoning, epidemic outbreaks,other
catastrophes/events that jeopardize the welfare and safety of clients, staff and/or members of the community): Click or tap here to
enter text.
Date of Incident:Click or tap here to enter text. Time of Incident: Click or tap here to enter text.❑am ❑pm
Location of Incident:Click or tap here to enter text.
Description of the Incident(Attach additional sheet if needed):Click or tap here to enter text.
Key People Directly Involved in Incident(witnesses,staff):Click or tap here to entertext.
Action Taken(check all that apply)
❑Consulted with Physician ❑ Called 911/EMS; ❑ First Aid/CPR Administered ❑ Law Enforcement Contacted
❑ Client removed from building ❑ Parent/Legal Guardian Contacted ❑Other(Specify):Click or tap here to enter text.
Description of Action Taken:Click or tap here to enter text.
Outcome of Incident(If Known): Click or tap here to enter text.
Form Completed by:
Printed Name Signature Date
Reviewed by Supervisor/Program Manager:
Printed Name Signature Date
For Internal Use only:
❑ Report to Administration ❑ Report to Intensive Analysis Committee for additional review ❑Request Additional Information
❑ No Action ❑ Unusual Occurrence ❑ Other:Click or tap here to enter text.
Revised 12/2017
Exhibit G
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers' offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit G
Page 2 of 2
Informal provider problem resolution process— the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process— the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider's claim to the MHP.
Payment authorization issues — the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider's claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints — if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
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EXHIBIT-L
Page 2 of 2
FIXED ASSET AND SENSITIVE ITEM TRACKING
Field Required or
Field Number Instruction or Comments
Description Conditional
Header Vendor Indicate the legal name of the agency contracted to Required
provide services.
Indicate the title of the project as described in the
Header Program Required
contract with the County.
Header Contract # Indicate the assigned County contract number. If not Required
known, County staff can provide.
Indicate the first and last name of the primary agency
Header Contact Person Required
contact for the contract.
Header Contact # Indicate the most appropriate telephone number of the Required
primary agency contact for the contract.
Indicate the most current date that the tracking form
Header Date Prepared was completed by the vendor. Required
a Item Identify the item by providing a commonly recognized Required
description of the item.
b Make/Brand Identify the company that manufactured the item. Required
c Model Identify the model number for the item, if applicable. Conditional
d Serial # Identify the serial number for the item, if applicable. Conditional
Mark the box with an "X" if the cost of the item is
e Fixed Asset $5,000 or more to indicate that the item is a fixed Conditional
asset.
Mark the box with an "X" if the item meets the criteria
f Sensitive Item Conditional
of a sensitive item as defined by the County.
Indicate the date that the agency submitted a request
g Date Requested Required
to the County to purchase the item.
Indicate the date that the County approved the request
h Date Approved Required
to purchase the item.
i Purchase Date Indicate the date the agency purchased the item. Required
j Location Indicate the physical location of the item Required
k Condition Indicate the general condition of the item (New, Good, Required
Worn, Bad) .
Fresno County
1 Inventory Indicate the FR # provided by the County for the item. Conditional
Number
m Cost Indicate the total purchase price of the item including Required
sales tax and other costs, such as shipping.
Exhibit M
Page 1 of 2
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care
disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse
cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Governance, Leadership, and Workforce:
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,
practices, and allocated resources.
3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are
responsive to the population in the service area.
4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and
practices on an ongoing basis.
Communication and Language Assistance:
5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at
no cost to them, to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their preferred language,
verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals
and/or minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the
populations in the service area.
Engagement, Continuous Improvement, and Accountability:
9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them
throughout the organization's planning and operations.
10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into
measurement and continuous quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health
equity and outcomes and to inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement
services that respond to the cultural and linguistic diversity of populations in the service area.
13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural
and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent,
and resolve conflicts or complaints.
15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and
the general public.
THINK
S.DePartm r#of www.ThinkCulturalHealth.hhs.gov CULTURAL —
Kealih "u""^Se� HEALTH •
O M H OiikeofMino, Hearn
Exhibit M
Page 2 of 2
The Case for the Enhanced National CLAS Standards
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
—Dr. Martin Luther King, Jr.
Health equity is the attainment of the highest level of health for all people (U.S. Department of Health and Human
Services [HHS] Office of Minority Health, 2011). Currently, individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of
health, or those conditions in which individuals are born, grow, live, work, and age (World Health Organization, 2012),
such as socioeconomic status, education level, and the availability of health services (HHS Office of Disease Prevention
and Health Promotion, 2010). Though health inequities are directly related to the existence of historical and current
discrimination and social injustice, one of the most modifiable factors is the lack of culturally and linguistically appropriate
services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of
all individuals.
Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely
affect neighborhoods, communities, and the broader society, thus making the issue not only an individual concern but
also a public health concern. In the United States, it has been estimated that the combined cost of health disparities and
subsequent deaths due to inadequate and/or inequitable care is $1.24 trillion (LaVeist, Gaskin, & Richard, 2009).
Culturally and linguistically appropriate services are increasingly recognized as effective in improving the quality of care
and services (Beach et al., 2004; Goode, Dunne, & Bronheim, 2006). By providing a structure to implement culturally and
linguistically appropriate services, the enhanced National CLAS Standards will improve an organization's ability to address
health care disparities.
The enhanced National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities
(HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity (HHS National Partnership for Action to
End Health Disparities, 2011), which aim to promote health equity through providing clear plans and strategies to guide
collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives, the
enhanced National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care
disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and
linguistically appropriate services. Adoption of these Standards will help advance better health and health care in the
United States.
Bibliography:
Beach,M.C.,Cooper,L.A.,Robinson,K.A.,Price,E.G.,Gary,T.L.,Jenckes,M.W.,Powe,N.R.(2004).Strategies for improving minority healthcare quality.(AHRQ
Publication No.04-E008-02).Retrieved from the Agency of Healthcare Research and Quality website:
http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/mi nqual.pdf
Goode,T.D.,Dunne,M.C.,&Bronheim,S.M.(2006).The evidence base for cultural and linguistic competency in health care.(Commonwealth Fund Publication No.962).
Retrieved from The Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf
LaVeist,T.A.,Gaskin,D.J.,&Richard,P.(2009).The economic burden of health inequalities in the United States.Retrieved from the Joint Center for Political and Economic
Studies website: http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2
0 Burden%20of%20 Health%20Ineq ual ities%20i n%20the%20U n ited%20States.pdf
National Partnership for Action to End Health Disparities.(2011).National stakeholder strategy for achieving health equity.Retrieved from U.S.Department of Health and
Human Services,Office of Minority Health website:http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
U.S.Department of Health and Human Services.(2011).HHS action plan to reduce racial and ethnic health disparities:A nation free of disparities in health and health care.
Retrieved from http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
U.S.Department of Health and Human Services,Office of Disease Prevention and Health Promotion.(2010).Healthy people 2020:Social determinants of health.Retrieved
from http://www.healthypeople.gov/2020/topicsobjectives2O2O/overview.aspx?topicid=39
U.S.Department of Health and Human Services,Office of Minority Health(2011).National Partnership for Action to End Health Disparities.Retrieved from
http://minorityhealth.hhs.gov/npa
World Health Organization.(2012).Social determinants of health.Retrieved from http://www.who.int/social_determinants/en/
l THINK
U.S.Deporhnenf of www.ThinkCulturalHealth.hhs.gov CULTURAL —
M Hedih and Hunwn Services HEALTH •
O, • ,H Office of mno, Heollh 1
Exhibit N
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address(number,street) City State ZIP code
CLIA number Taxpayer ID number(EIN) /Telephone number
)
II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and
addresses of individuals or corporations under"Remarks"on page 2. Identify each item number to be continued.
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 XVII I, XIX, or XX? ......................................................................................................................... o 0
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX?...................................................................................... 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 XVIII 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...........................................................................................................
NAME ADDRESS PROVIDER NUMBER
Exhibit N
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? ...................................................................................................................... o 0
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 O
Page 1 of 2
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit O
Page 2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit P
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest"
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member's name,job title (if applicable), and date this disclosure is being made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation's transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit P
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 Q C T L I F O R N I G D F P G R T M F N T OF
Page 1 of30 Mental Health T 6/ PAF
6/2/06
FULL SERVICE PARTNERSHIP
Transition Age Youth Partnership Assessment Form
FOR AGES 16-25 YEARS
PARTNERSHIP INFORMATION
County Number CSI County Client Number Unique County ID (optional)
m
Youth's First Name Youth's Last Name
Partnership Date (mmddyyyy) Youth's Date of Birth (mmddyyyy)
m m m m
Who referred the youth? (mark one)
O Self O Mental Health Facility/ Community Agency O Juvenile Hall / Camp/ Ranch /
California Youth Authority
O Family Member (e.g.,parent,guardian, O Social Services Agency
sibling,aunt,uncle,grandparent)
O Jail / Prison
O Significant Other O Substance Abuse Treatment Facility/Agency
(e.g.,boyfriend/girlfriend,spouse)
O Acute Psychiatric/State Hospital
O Friend/Neighbor (i.e.,unrelated other) O Faith-based Organization
O School O Other County/Community Agency O Other
O Primary Care/ Medical Office O Homeless Shelter
O Emergency Room O Street Outreach
ADMINISTRATIVE -
MATION
Provider Site ID Full Service Partnership Program ID Partnership Service Coordinator ID
In which programs is the youth CURRENTLY involved? (mark all that apply)
O AB2034 O Governor's Homeless Initiative (GHI) O Transition Age Youth Program
Page 1 of 8
Exhibit Q
Page 2 of 30 TAY PAF
6/2/06
RESIDENTIAL INFORMATION
(includes hospitalization and incarceration)
TONIGHT YESTERDAY DURING THE PAST 12 MONTHS PRIOR
Setting ,as of 11:59 p.m. indicate the TOTAL: TO THE LAST
g the day BEFORE #Days 12 MONTHS
partnership) #Occurrences must=365 (mark all that apply)
GENERAL LIVING ARRANGEMENT
With one or both biological/adoptive parents 0 0 0
With adult family member(s)other than parents-non-foster care 0 0 0
In an apartment or house alone/with spouse/partner/minor children/ 0 0 0
other dependents/roommate-must hold lease or share in rent/mortgage
Single Room Occupancy(must hold lease) 0 0 0
Foster Home(with relative) 0 0 0
Foster Home(with non-relative) 0 0 0
SHELTER/HOMELESS
Emergency Shelter/Temporary Housing(includes people living With friends but 0 0 0
paying no rent)
Homeless(includes people living in their cars) 0 0 0
SUPERVISED PLACEMENT
Unlicensed but supervised individual placement(includes paid caretakers,personal 0 0 0
care attendants,etc.)
Unlicensed but supervised congregate placement(includes group living homes, 0 0 0
sober living homes)
Licensed Community Care Facility(Board and Care) 0 0 0
HOSPITAL
Acute Medical Hospital 0 0 Q
Acute Psychiatric Hospital/Psychiatric Health Facility(PHF) 0 0 0
State Psychiatric Hospital 0 0 0
RESIDENTIAL PROGRAM
Group Home(Level 0-11) 0 0 0
Group Home(Level 12-14) 0 0 0
Community Treatment Facility 0 0 0
Licensed Residential Treatment(includes crisis,short-term,long-term,substance abuse, O O O
dual diagnosis residential programs)
Skilled Nursing Facility(physical) 0 0 0
Skilled Nursing Facility(psychiatric) 0 0 0
Long-Term Institutional Care(IMD, MHRC) 0 0 0
JUSTICE PLACEMENT
Juvenile Hall/Camp/Ranch 0 0 0
California Youth Authority 0 0 0
Jail 0 O T77 1 1. 11 0
Prison 0 O O
Other 0 O O
Unknown 0 O =E= 0
Page 2 of 8
Exhibit Q
Page 3 of 30 TAY PAF
6/2/06
Highest level of education completed:
O Day Care O 6th Grade O High School Diploma/GED O Master's degree (e.g., M.A., M.S.W.)
O Pre-School O 7th Grade O Less than 2 years college/ O 3-4 years graduate training
O Kindergarten O 8th Grade Some Technical/Vocational Training O Doctoral degree (e.g., M.D., Ph.D.)
O 1st Grade O 9th Grade O AA degree O Level Unknown
O 2nd Grade O 10th Grade O Technical/Vocational Degree (e.g., youth in non-public school)
O 3rd Grade O 11th Grade O 3-4 years college
O 4th Grade O 12th Grade O Bachelor's Degree (B.A., B.S.)
O 5th Grade O GED Coursework O Less than 2 years graduate school
Is the youth CURRENTLY receiving special education due to serious emotional disturbance? O Yes O No
Is the youth CURRENTLY receiving special education due to another reason? O Yes O No
FOR YOUTH WHO ARE REQUIRED BY LAW TO ATTEND SCHOOL:
Estimate the youth's attendance*level Estimate the youth's attendance* level
DURING THE PAST 12 MONTHS: CURRENTLY:
O Always attends school (never truant) O Always attends school (never truant)
O Attends school most of the time O Attends school most of the time
O Sometimes attends school O Sometimes attends school
O Infrequently attends school O Infrequently attends school
O Never attends school O Never attends school
CURRENTLY, his/her grades are: O Very Good O Good O Average O Below Average O Poor
DURING THE PAST 12 MONTHS, his/her grades were: O Very Good O Good O Average O Below Average O Poor
DURING THE PAST 12 MONTHS, how many times has s/he been suspended? m
DURING THE PAST 12 MONTHS, how many times has s/he been expelled? m
FOR YOUTH WHO ARE NOT REQUIRED BY LAW TO ATTEND SCHOOL:
was DURING
For the educational settings below, indicate where the THE PAST 12 MONTHS is CURRENTLY
youth... #of weeks (mark all that apply)
Not in school of any kind m O
High School /Adult Education m O
Technical /Vocational School m O
Community College/4 year College m O
Graduate School m O
Other m O
Does one of the youth's current recovery goals include any kind of education at this time? O Yes O No
*excludes scheduled breaks and excused absences Page 3 of 8
Exhibit Q
Page 4 of 30 TAY PAF
6/2/06
EMPLOYMENT
EMPLOYMENT DURING THE PAST 12 MONTHS
Indicate the youth's employment status...
AVERAGE AVERAGE
61 #OF WEEKS HOURSMEEKQft HOURLY WAGE
Competitive Employment: m m � m
Paid employment in the community in a position that is also
open to individuals without a disability.
Supported Employment: m m m Competitive Employment(see above)with ongoing on-site or
off-site job-related support services provided.
Transitional Employment/Enclave: m m .m
Paid jobs in the community that are 1)open only to individuals
with a disability AND 2)are either time-limited for the purpose of
moving to a more permanent job OR are part of a group of
disabled individuals who are working as a team in the midst of
teams of non-disabled individuals who are performing the same
work.
Paid In-House Work(Sheltered Workshop/Work
Experience/Agency-Owned Business):
Paid jobs open only to program participants with a disability. A
Sheltered Workshop usually offers sub-minimum wage work in a
simulated environment. A Work Experience (Adjustment)
Program within an agency provides exposure to the standard
expectations and advantages of employment. An
Agency-Owned Business serves customers outside the agency
and provides realistic work experiences and can be located at
the program site or in the community.
Non-paid (Volunteer)Work Experience: m m
Non-paid (volunteer)jobs in an agency or volunteer work in the
community that provides exposure to the standard expectations
of employment.
Other Gainful/Employment Activity:
Any informal employment activity that increases the youth's
income(e.g., recycling,gardening, babysitting)OR participation
in formal structured classes and/or workshops providing
instruction on issues pertinent to getting a job. (Does NOT
include such activities as panhandling or illegal activities such
as prostitution).
Unemployed m
Page 4 of 8
Exhibit Q
Page 5 of 30 TAY PAF
6/2/06
CURRENT EMPLOYMENT
Indicate the youth's employment status... AVERAGE
HOURSIWEEK HOURLY WAGE
Competitive Employment: m � m Paid employment in the community in a position that is also
open to individuals without a disability.
Supported Employment: m m Competitive Employment(see above)with ongoing on-site or
off-site job-related support services provided.
Transitional Employment/Enclave: m $ � m Paid jobs in the community that are 1)open only to individuals
with a disability AND 2)are either time-limited for the purpose of
moving to a more permanent job OR are part of a group of
disabled individuals who are working as a team in the midst of
teams of non-disabled individuals who are performing the same
work.
Paid In-House Work(Sheltered Workshop/Work Experience/Agency-Owned Business):
Paid jobs open only to program participants with a disability. A
Sheltered Workshop usually offers sub-minimum wage work in a
simulated environment. A Work Experience (Adjustment)
Program within an agency provides exposure to the standard
expectations and advantages of employment. An
Agency-Owned Business serves customers outside the agency
and provides realistic work experiences and can be located at
the program site or in the community.
Non-paid (Volunteer)Work Experience: m
Non-paid (volunteer)jobs in an agency or volunteer work in the
community that provides exposure to the standard expectations
of employment.
Other Gainful/Employment Activity:
Any informal employment activity that increases the youth's
income(e.g., recycling, gardening, babysitting)OR participation
in formal structured classes and/or workshops providing
instruction on issues pertinent to getting a job. (Does NOT
include such activities as panhandling or illegal activities such
as prostitution).
Check here if the youth is not employed at this time: ❑
Does one of the youth's current recovery goals include any kind of employment at this time? O Yes O No
Page 5 of 8
Exhibit Q
Page 6 of 30 TAY PAF
6/2/06
SOURCESSUPPORT
Indicate all the sources of financial support used DURING THE
to meet the needs of the youth: PAST 12 MONTHS CURRENTLY
(mark all that apply) (mark all that apply)
Caregiver's Wages O O
Youth's Wages O O
Youth's Spouse/Significant Other's Wages O O
Savings O O
Child Support O O
Other Family Member/Friend O O
Retirement/Social Security Income O O
Veteran's Assistance Benefits O O
Loan/Credit O O
Housing Subsidy O O
General Relief/General Assistance O O
Food Stamps O O
Temporary Assistance for Needy Families (TANF) O O
Supplemental Security Income/State Supplementary Payment(SSI/SSP)Program O O
Social Security Disability Insurance (SSDI) O O
State Disability Insurance (SDI) O O
American Indian Tribal Benefits O O
(e.g., per capita, revenue sharing, trust disbursements)
Other O O
Page 6 of 8
Exhibit Q
Page 7 of 30 TAY PAF
6/2/06
LEGAL ISSUES / DESIGNATIONS
JUSTICE SYSTEM INVOLVEMENT
ARREST INFORMATION m
Indicate the number of times the youth was arrested DURING THE PAST 12 MONTHS:
Was the youth arrested anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
PROBATION INFORMATION
Is the youth CURRENTLY on probation? O Yes O No
Was the youth on probation DURING THE PAST 12 MONTHS? O Yes O No
Was the youth on probation anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
PAROLE INFORMATION
Is the youth CURRENTLY on parole? O Yes O No
Was the youth on parole DURING THE PAST 12 MONTHS? O Yes O No
Was the youth on parole anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
CONSERVATORSHIP / PAYEE INFORMATION
CONSERVATORSHIP INFORMATION
Is the youth CURRENTLY on conservatorship? O Yes O No
Was the youth on conservatorship DURING THE PAST 12 MONTHS? O Yes O No
Was the youth on conservatorship anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
PAYEE INFORMATION
Does the youth CURRENTLY have a payee? O Yes O No
Did the youth have a payee DURING THE PAST 12 MONTHS? O Yes O No
Did the youth have a payee anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
DEPENDENT (W & I CODE 300 STATUS) INFORMATION
Is the youth CURRENTLY a dependent of the court? O Yes O No
Was the youth a dependent of the court DURING THE PAST 12 MONTHS? O Yes O No
Was the youth a dependent of the court anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
If the youth was ever a dependent of the court, indicate the year
the youth was first placed on W & I Code 300 status:
CUSTODY INFORMATION
Indicate the total number of children the partner has who are CURRENTLY:
Placed on W& I Code 300 Status: m
(Dependent of the court)
Placed in Foster Care: m
Legally reunified with partner: m
Adopted out: m
Page 7 of 8
Exhibit Q
Page 8 of 30 TAY PAF
6/2/06
EMERGENCY •
Please indicate the number of emergency interventions (e.g., emergency room visit, crisis stabilization unit) the
youth had DURING THE PAST 12 MONTHS that were:
mPhysical Health Related m Mental Health/Substance Abuse Related
HEALTH STATUS
Does the youth have a primary care physician CURRENTLY? O Yes O No
Did the youth have a primary care physician DURING THE PAST 12 MONTHS? O Yes O No
SUBSTANCE ABUSE
In the opinion of the partnership service coordinator, does the youth have a co-occurring
mental illness and substance use problem? O Yes O No
Is this an active problem? O Yes O No
Is the youth CURRENTLY receiving substance abuse services? O Yes O No
COUNTY USE QUESTIONS
To be tracked on the KEY EVENT TRACKING form:
County Use Field #1
County Use Field #2
County Use Field #3
ELI-
To be tracked on the QUARTERLY ASSESSMENT form:
County Use Field #1
County Use Field #2
County Use Field #3
Page 8 of 8
Exhibit Q CALIFORNIA DEPARTMENT OF
Page 9 of 30 A, ADULT PAF
yMental Health 6/2/06
FULL SERVICE PARTNERSHIP
Adult Partnership Assessment Form
FOR AGES 26-59 YEARS
PARTNERSHIP INFORMATION
County Number CSI County Client Number Unique County ID (optional)
m
Partner's First Name Partner's Last Name
I I � � I I I � � I I I � M-17 I � I I I I I I � I I 1 11
Partnership Date (mmddyyyy) Partner's Date of Birth (mmddyyyy)
m m m m
Who referred the partner? (mark one)
O Self O Mental Health Facility/Community Agency O Jail / Prison
O Family Member (e.g.,parent,guardian, O Social Services Agency O Acute Psychiatric/State Hospital
sibling,aunt,uncle,grandparent,child)
O Significant Other O Substance Abuse Treatment Facility/Agency O Other
(e.g.,boyfriend/girlfriend,spouse)
O Friend/Neighbor (i.e.,unrelated other) O Faith-based Organization
O School O Other County/Community Agency
O Primary Care/ Medical Office O Homeless Shelter
O Emergency Room O Street Outreach
ADMINISTRATIVE -
MATION
Provider Site ID Full Service Partnership Program ID Partnership Service Coordinator ID
In which programs is the partner CURRENTLY involved? (mark all that apply)
O AB2034 O Governor's Homeless Initiative (GHI)
Page 1 of 8
Exhibit Q
Page 10 of 30
RESIDENTIALINFORMATION
(includes hospitalization and incarceration)
YESTERDAY DURING THE PAST 12 MONTHS PRIOR
TONIGHT (as of`111:5s p.m. indicate the TOTAL: TO THE LAST
Setting the day BEFORE #Days 12 MONTHS
partnership) #Occurrences (must=365) (mark all Matapply)
GENERAL LIVING ARRANGEMENT
In an apartment or house alone/with spouse/partner/minor children/ O O 0
other dependents/roommate-must hold lease or share in rent/mortgage
With one or both biological/adoptive parents 0 0 0
With adult family member(s)other than parents 0 0 0
Single Room Occupancy(must hold lease) 0 0 0
SHELTER/HOMELESS
Emergency Shelter/Temporary Housing(includes people living with friends but 0 0 0
paying no rent)
Homeless(includes people living in their cars) 0 0 0
SUPERVISED PLACEMENT
Unlicensed but supervised individual placement(includes paid caretakers,personal 0 0 0
care attendants,etc.)
Assisted Living Facility 0 0 0
Unlicensed but supervised congregate placement(includes group living homes, 0 0 0
sober living homes)
Licensed Community Care Facility(Board and Care) 0 0 0
HOSPITAL
Acute Medical Hospital 0 0 0
Acute Psychiatric Hospital/Psychiatric Health Facility(PHF) 0 0 0
State Psychiatric Hospital 0 0 0
RESIDENTIAL PROGRAM
Licensed Residential Treatment(includes crisis,short-term,long-term,substance abuse, 0 0 0
dual diagnosis residential programs)
Skilled Nursing Facility(physical) 0 0 0
Skilled Nursing Facility(psychiatric) 0 0 0
Long-Term Institutional Care(IMD, MHRC) 0 0 0
JUSTICE PLACEMENT
Jail 0 O 0
Prison 0 0 0
Other 0 0 0
Unknown 0 0 0
Page 2 of 8
Exhibit Q
Pa e 11 of 30
Highest level of education completed:
O No High School Diploma/ No GED O AA degree O Less than 2 years graduate school
O GED Coursework O Technical/Vocational Degree O Master's degree (e.g., M.A., M.S.W.)
O High School Diploma/ GED O 3-4 years college O 3-4 years graduate training
O Less than 2 years college/ O Bachelor's Degree (B.A., B.S.) O Doctoral degree (e.g., M.D., Ph.D.)
Some Technical/Vocational Training
was DURING
For the educational settings below, indicate where the THE PAST 12 MONTHS is CURRENTLY 01
partner... #of weeks (mark all that apply)
Not in school of any kind m O
High School /Adult Education m O
Technical /Vocational School m O
Community College/4 year College m O
Graduate School m O
Other m O
Does one of the partner's current recovery goals include any kind of education at this time? O Yes O No
Page 3 of 8
Exhibit Q
pnnin
EMPLOYMENT
EMPLOYMENT DURING THE PAST 12 MONTHS
Indicate the partner's employment status... AVERAGE AVERAGE
#OF WEEKS HOURS/WEEK HOURLY WAGE
Competitive Employment: m m � m
Paid employment in the community in a position that is also
open to individuals without a disability.
Supported Employment: m m m Competitive Employment(see above)with ongoing on-site or
off-site job-related support services provided.
Transitional Employment/Enclave: m m m Paid jobs in the community that are 1)open only to individuals
with a disability AND 2)are either time-limited for the purpose of
moving to a more permanent job OR are part of a group of
disabled individuals who are working as a team in the midst of
teams of non-disabled individuals who are performing the same
work.
Paid In-House Work(Sheltered Workshop/Work
Experience/Agency-Owned Business):
Paid jobs open only to program participants with a disability. A
Sheltered Workshop usually offers sub-minimum wage work in a
simulated environment. A Work Experience(Adjustment)
Program within an agency provides exposure to the standard
expectations and advantages of employment. An
Agency-Owned Business serves customers outside the agency
and provides realistic work experiences and can be located at
the program site or in the community.
Non-paid (Volunteer)Work Experience: m m
Non-paid (volunteer)jobs in an agency or volunteer work in the
community that provides exposure to the standard expectations
of employment.
Other Gainful/Employment Activity:
Any informal employment activity that increases the partner's
income (e.g., recycling, gardening, babysitting)OR participation
in formal structured classes and/or workshops providing
instruction on issues pertinent to getting a job. (Does NOT
include such activities as panhandling or illegal activities such
as prostitution).
Unemployed m
Page 4 of 8
Exhibit Q
Page 13 of 30
CURRENT EMPLOYMENT
Indicate the partner's employment status... AVERAGE
HOURSIWEEK HOURLY WAGE
Competitive Employment: m � m Paid employment in the community in a position that is also
open to individuals without a disability.
Supported Employment: m m Competitive Employment(see above)with ongoing on-site or
off-site job-related support services provided.
Transitional Employment/Enclave: m $ � m Paid jobs in the community that are 1)open only to individuals
with a disability AND 2)are either time-limited for the purpose of
moving to a more permanent job OR are part of a group of
disabled individuals who are working as a team in the midst of
teams of non-disabled individuals who are performing the same
work.
Paid In-House Work(Sheltered Workshop/Work Experience/Agency-Owned Business):
Paid jobs open only to program participants with a disability. A
Sheltered Workshop usually offers sub-minimum wage work in a
simulated environment. A Work Experience (Adjustment)
Program within an agency provides exposure to the standard
expectations and advantages of employment. An
Agency-Owned Business serves customers outside the agency
and provides realistic work experiences and can be located at
the program site or in the community.
Non-paid (Volunteer)Work Experience: m
Non-paid (volunteer)jobs in an agency or volunteer work in the
community that provides exposure to the standard expectations
of employment.
Other Gainful/Employment Activity:
Any informal employment activity that increases the partner's
income(e.g., recycling, gardening, babysitting)OR participation
in formal structured classes and/or workshops providing
instruction on issues pertinent to getting a job. (Does NOT
include such activities as panhandling or illegal activities such
as prostitution).
Check here if the partner is not employed at this time: ❑
Does one of the partner's current recovery goals include any kind of employment at this time? O Yes O No
Page 5 of 8
Exhibit Q
Page 14 of 30
SOURCES . . L SUPPOR
Indicate all the sources of financial support used DURING THE
to meet the needs of the partner: PAST 12 MONTHS CURRENTLY
(mark all that apply) (mark all that apply)
Partner's Wages O O
Partner's Spouse/Significant Other's Wages O O
Savings O O
Other Family Member/Friend O O
Retirement/Social Security Income O O
Veteran's Assistance Benefits O O
Loan/Credit O O
Housing Subsidy O O
General Relief/General Assistance O O
Food Stamps O O
Temporary Assistance for Needy Families (TANF) O O
Supplemental Security Income/State Supplementary Payment(SSI/SSP)Program O O
Social Security Disability Insurance (SSDI) O O
State Disability Insurance (SDI) O O
American Indian Tribal Benefits O O
(e.g., per capita, revenue sharing,trust disbursements)
Other O O
Page 6 of 8
Exhibit Q
Page 15 of 30
LEGAL ISSUES / DESIGNATIONS
JUSTICE SYSTEM INVOLVEMENT
ARREST INFORMATION m
Indicate the number of times the partner was arrested DURING THE PAST 12 MONTHS:
Was the partner arrested anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
PROBATION INFORMATION
Is the partner CURRENTLY on probation? O Yes O No
Was the partner on probation DURING THE PAST 12 MONTHS? O Yes O No
Was the partner on probation anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
PAROLE INFORMATION
Is the partner CURRENTLY on parole? O Yes O No
Was the partner on parole DURING THE PAST 12 MONTHS? O Yes O No
Was the partner on parole anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
CONSERVATORSHIP / PAYEE INFORMATION
CONSERVATORSHIP INFORMATION:
Is the partner CURRENTLY on conservatorship? O Yes O No
Was the partner on conservatorship DURING THE PAST 12 MONTHS? O Yes O No
Was the partner on conservatorship anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
PAYEE INFORMATION:
Does the partner CURRENTLY have a payee? O Yes O No
Did the partner have a payee DURING THE PAST 12 MONTHS? O Yes O No
Did the partner have a payee anytime PRIOR TO THE LAST 12 MONTHS? O Yes O No
CUSTODY INFORMATION
Indicate the total number of children the partner has who are CURRENTLY
Placed on W & I Code 300 Status: m
(Dependent of the court)
Placed in Foster Care: m
Legally Reunified with partner: m
Adopted out: m
Page 7 of 8
Exhibit Q
Page 16 of 30
INTERVENTIONEMERGENCY
Please indicate the number of emergency interventions (e.g., emergency room visit, crisis stabilization unit) the
partner had DURING THE PAST 12 MONTHS that were:
mPhysical Health Related m Mental Health/Substance Abuse Related
HEALTH STATUS
Does the partner have a primary care physician CURRENTLY? O Yes O No
Did the partner have a primary care physician DURING THE PAST 12 MONTHS? O Yes O No
SUBSTANCE ABUSE
In the opinion of the partnership service coordinator, does the partner have a co-occurring
mental illness and substance use problem? O Yes O No
Is this an active problem? O Yes O No
Is the partner CURRENTLY receiving substance abuse services? O Yes O No
COUNTYQUESTIONS
To be tracked on the KEY EVENT TRACKING form:
County Use Field #1
County Use Field #2
County Use Field #3
ELI-
To be tracked on the QUARTERLY ASSESSMENT form:
County Use Field #1
County Use Field #2
County Use Field #3
Page 8 of 8
Exhibit Q C T L I F O R N I G D F P G R T M F N T OF
Page 17of30 Mental Health TAY3M
6/2/06
FULL SERVICE PARTNERSHIP
Transition Age Youth Quarterly Assessment Form
FOR AGES 16-25 YEARS
PARTNERSHIP INFORMATION
County Number CSI County Client Number Unique County ID (optional)
m
Youth's First Name Youth's Last Name
Date Completed (mmddyyyy) Youth's Date of Birth (mmddyyyy)
Is the youth CURRENTLY receiving special education due to serious emotional disturbance? O Yes O No
Is the youth CURRENTLY receiving special education due to another reason? O Yes O No
FOR YOUTH WHO ARE REQUIRED BY LAW TO ATTEND SCHOOL:
Estimate the youth's attendance level CURRENTLY, his/her grades are:
CURRENTLY: O Very Good
O Always attends school (never truant) O Good
O Attends school most of the time O Average
O Sometimes attends school O Below Average
O Infrequently attends school O Poor
O Never attends school
Page 1 of 3
Exhibit Q
Page 18 of 30 TAY 3M
6/2/06
SOURCES . . SUPPORT
Indicate all the sources of financial support that are CURRENTL
used to meet the needs of the youth (mark all that apply):
O Caregiver Wages
O Youth Wages
O Youth's Spouse/Significant Other's Wages
O Savings
O Child Support
O Other Family Member/ Friend
O Retirement/Social Security Income
O Veteran's Assistance Benefits
O Loan/Credit
O Housing Subsidy
O General Relief/General Assistance
O Food Stamps
O Temporary Assistance for Needy Families (TANF)
O Supplemental Security Income/State Supplementary
Payment(SSI/SSP) Program
O Social Security Disability Insurance (SSDI)
O State Disability Insurance (SDI)
O American Indian Tribal Benefits
(e.g., per capita, revenue sharing, trust disbursements)
O Other
LEGAL ISSUES / DESIGNATIONS
CUSTODY INFORMATION
Indicate the total number of children the partner has who are CURRENTLY
Placed on W & I Code 300 Status: m
(Dependent of the court)
Placed in Foster Care: m
Legally Reunified with partner: m
Adopted out: m
HEALTH STATUS
Does the youth have a primary care physician CURRENTLY? O Yes O No
SUBSTANCE ABUSE
In the opinion of the partnership service coordinator, does the youth have a
co-occurring mental illness and substance use problem? O Yes O No
Is this an active problem? O Yes O No
Is the youth CURRENTLY receiving substance abuse services? O Yes O No
Page 2 of 3
Exhibit Q
Page 19 of 30 TAY 3M
6/2/06
COUNTYQUESTIONS
Indicate NEW County Use Field #1
Indicate NEW County Use Field #2
Indicate NEW County Use Field #3
Page 3 of 3
Exhibit C AL I F 0 XN IA D FP ■ X TM I OF
Page 20 of 30 AMental Health ADULT 3M
6/2/06
FULL SERVICE PARTNERSHIP
Adult Quarterly Assessment Form
FORAGES 26-59 YEARS
PARTNERSHIP INFORMATION
County Number CSI County Client Number Unique County ID (optional)
m
Partner's First Name Partner's Last Name
Date Completed (mmddyyyy) Partner's Date of Birth (mmddyyyy)
m m m m
SOURCES OF • •
Ln
dicate all the sources of financial support that are CURRENTLY
used to meet the needs of the partner(mark all that apply):
O Partner's Wages
O Partner's Spouse/Significant Other's Wages
O Savings
O Other Family Member/Friend
O Retirement/Social Security Income
O Veteran's Assistance Benefits
O Loan/Credit
O Housing Subsidy
O General Relief/General Assistance
O Food Stamps
O Temporary Assistance for Needy Families (TANF)
O Supplemental Security Income/State Supplementary
Payment(SSI/SSP)Program
O Social Security Disability Insurance(SSDI)
O State Disability Insurance (SDI)
O American Indian Tribal Benefits
(e.g., per capita, revenue sharing,trust disbursements)
O Other
Page 1 of 2
Exhibit Q
Page 21 of 30 ADULT 3M
6/2/06
LEGAL •
CUSTODY INFORMATION
Indicate the total number of children the partner has who are CURRENTLY:
Placed on W & I Code 300 Status: m
(Dependent of the court)
Placed in Foster Care: m
Legally reunified with partner: m
Adopted out: m
HEALTH STATUS
Does the partner have a primary care physician CURRENTLY? O Yes O No
SUBSTANCE ABUSE
In the opinion of the partnership service coordinator, does the partner have a
co-occurring mental illness and substance use problem? O Yes O No
Is this an active problem? O Yes O No
Is the partner CURRENTLY receiving substance abuse services? O Yes O No
COUNTY USE QUESTIONS
Indicate NEW County Use Field #1
Indicate NEW County Use Field #2
Indicate NEW County Use Field #3
Page 2 of 2
Exhibit Q C T L I F O R N I G D F P G R T M F N T OF
Page 22of30 Mental Health TAYKET
6/2/06
FULL SERVICE PARTNERSHIP
Transition Age Youth Key Event Tracking Form
FORAGES 16-25 YEARS
PARTNERSHIP INFORMATION
County Number CSI County Client Number Unique County ID (optional)
m
Youth's First Name Youth's Last Name
Date Completed (mmddyyyy) Youth's Date of Birth (mmddyyyy)
CHANGE IN m m m m
ADMINISTRATIVE -
(skip this section if there are no changes)
Is the youth CURRENTLY involved in:
YES NO Date of AB2034 change (mmddyyyy):
AB2034 O O m m
YES NO Date of Governor's Homeless Initiative (GHI) change (mmddyyyy):
Governor's Homeless Initiative (GHI) O O m m
Date of Transition Age Youth Program change (mmddyyyy):
YES NO m m
Transition Age Youth Program O O
Date of Provider Site ID Change (mmddyyyy): NEW Provider Site ID
m m
Date of Full Service Partnership Program ID Change (mmddyyyy): NEW Full Service Partnership Program ID
m m
Date of Partnership Service Coordinator ID Change (mmddyyyy): NEW Partnership Service Coordinator ID
m m - 1 1 1 1 � T_� � � � � I I
Date of Partnership Status Change (mmddyyyy): Indicate new partnership status:
m m O Discontinuation/Interruption of Full O Reestablishment of
Service Partnership and/or Full Service Partnership and/or
community services/program community services/program
(indicate reason below)
If there is a DISCONTINUATION/INTERRUPTION of Full Service Partnership and/or community services/program,
indicate the reason (mark one):
O Target population criteria are not met.
O Youth decided to discontinue Full Service Partnership participation after partnership established.
O Youth moved to another county/service area.
O After repeated attempts to contact youth, s/he cannot be located.
O Community services/program interrupted -Youth's circumstances reflect a need for residential/institutional
mental health services at this time (such as IMD, MHRC, State Hospital).
O Community services/program interrupted -Youth will be serving jail/prison sentence.
O Youth has successfully met his/her goals such that discontinuation of Full Service Partnership is appropriate.
0 Youth is deceased. Page 1 of 5
Exhibit Q
Page 23 of 30 TAY KET
6/2/06
RESIDENTIAL INFORMATION - includes hospitalization and incarceration
(skip this section if there are no changes)
Date of Residential Status Change (mmddyyyy):
Indicate the new residential status (mark one):
GENERAL LIVING ARRANGEMENT RESIDENTIAL PROGRAM
0 With one or both biological/adoptive parents 0 Group Home(Level 0-11)
0 With adult family member(s)other than parents-non-foster care 0 Group Home(Level 12-14)
0 In an apartment or house alone/with spouse/partner/minor children/
other dependents/roommate-must hold lease or share in rent/mortgage 0 Community Treatment Facility
0 Single Room Occupancy(must hold lease) 0 Licensed Residential Treatment(includes crisis,short-term,
0 Foster Home(with relative) long-term,substance abuse,dual diagnosis residential programs)
0 Foster Home(with non-relative) 0 Skilled Nursing Facility(physical)
SHELTER/HOMELESS 0 Skilled Nursing Facility(psychiatric)
0 Emergency Shelter/Temporary Housing(includes people living with friends but 0 Long-Term Institutional Care(IMD, MHRC)
paying no rent)
O Homeless(includes people living in their cars) JUSTICE PLACEMENT
SUPERVISED PLACEMENT 0 Juvenile Hall/Camp/Ranch
0 Unlicensed but supervised individual placement(includes paid caretakers,
personal care attendants,etc.) 0 California Youth Authority
0 Unlicensed but supervised congregate placement(includes group living homes, 0 Jail
sober living homes)
0 Licensed Community Care Facility(Board and Care) 0 Prison
HOSPITAL 0 Other
0 Acute Medical Hospital
0 Acute Psychiatric Hospital/Psychiatric Health Facility(PHF) 0 Unknown
0 State Psychiatric Hospital
Page 2 of 5
Exhibit Q
Page 24 of 30 TAY KET
6/2/06
EDUCATION
(skip this section if there are no . -
GRADE LEVEL INFORMATION
Date of Grade Level Completion (mmddyyyy)
m m
Level of education completed:
O Day Care O 6th Grade O High School Diploma/GED O Less than 2 years graduate school
O Pre-School O 7th Grade O Less than 2 years college/ O Master's degree (e.g., M.A., M.S.W.)
O Kindergarten O 8th Grade Some Technical /Vocational Training O 3-4 years graduate training
O 1st Grade O 9th Grade O AA degree O Doctoral degree (e.g., M.D., Ph.D.)
O 2nd Grade O 10th Grade O Technical/Vocational Degree O Level Unknown
O 3rd Grade O 11th Grade O 3-4 years college (e.g., youth in non-public school)
O 4th Grade O 12th Grade O Bachelor's Degree (B.A., B.S.)
O 5th Grade O GED Coursework
SUSPENSION INFORMATION EXPULSION INFORMATION
Date of Suspension (mmddyyyy) Date of Expulsion (mmddyyyy)
m m m m
FOR YOUTH WHO ARE NOT REQUIRED BY LAW TO ATTEND SCHOOL:
EDUCATIONAL SETTING INFORMATION
Date of Educational Setting Change (mmddyyyy) Indicate the new educational settinq(s) (mark all that apply):
mm O Not in school of any kind
O High School /Adult Education
O Technical /Vocational School
O Community College/4 year College
O Graduate School
O Other
If stopping school, did the youth complete a class and/or program? O Yes O No
Does one of the youth's current recovery goals include any kind of education at this time? O Yes O No
Page 3 of 5
Exhibit Q
Page 25 of 30 TAY KET
6/2/06
EMPLOYMENT
(skip this section if there are no changes)
Date of Employment Change (mmddyyyy): [11 [11
CURRENT EMPLOYMENT
Indicate the youth's employment status... AVERAGE
HOURS/WEEK HOURLY WAGE
Competitive Employment: m � .m
Paid employment in the community in a position that is also
open to individuals without a disability.
Supported Employment: m m Competitive Employment(see above)with ongoing on-site or
off-site job-related support services provided.
Transitional Employment/Enclave: m $ � m Paid jobs in the community that are 1)open only to individuals
with a disability AND 2)are either time-limited for the purpose of
moving to a more permanent job OR are part of a group of
disabled individuals who are working as a team in the midst of
teams of non-disabled individuals who are performing the same
work.
Paid In-House Work(Sheltered Workshop/Work
Experience/Agency-Owned Business):
Paid jobs open only to program participants with a disability. A
Sheltered Workshop usually offers sub-minimum wage work in a
simulated environment. A Work Experience (Adjustment)
Program within an agency provides exposure to the standard
expectations and advantages of employment. An
Agency-Owned Business serves customers outside the agency
and provides realistic work experiences and can be located at
the program site or in the community.
Non-paid (Volunteer)Work Experience: m
Non-paid (volunteer)jobs in an agency or volunteer work in the
community that provides exposure to the standard expectations
of employment.
Other Gainful/Employment Activity:
Any informal employment activity that increases the youth's
income(e.g., recycling, gardening, babysitting)OR participation
in formal structured classes and/or workshops providing
instruction on issues pertinent to getting a job. (Does NOT
include such activities as panhandling or illegal activities such
as prostitution).
Check here if the youth is not employed at this time: ❑
Does one of the youth's current recovery goals include any kind of employment at this time? O Yes O No
Page 4 of 5
Exhibit Q
Page 26 of 30 TAY KET
6/2/06
LEGALDESIGNATIONS
(skip this section if there are no . -
ARREST INFORMATION
Date Youth Arrested (mmddyyyy): m m
PROBATION / PAROLE INFORMATION
Date of Probation Status Change (mmddyyyy): Indicate new probation status:
m m I I I 1
O Removed From Probation O Placed on Probation
Date of Parole Status Change (mmddyyyy):
Indicate new parole status:
m m I I I 1 O Removed From Parole O Placed on Parole
CONSERVATORSHIP / PAYEE INFORMATION
Date of Conservatorship
Status Change (mmddyyyy): Indicate new conservatorship status:
mm I I I 1 O Removed from conservatorship O Placed on conservatorship
Date of Payee Status Change (mmddyyyy): Indicate new payee status:
mm I I I 1 O Removed from payee status O Placed on payee status
DEPENDENT (W & I CODE 300 STATUS) INFORMATION
Date of W & I Code 300 Indicate new W&I Code 300 status:
Status Change (mmddyyyy):
m m O Removed From O Placed on
W & I Code 300 Status W & I Code 300 Status
INTERVENTIONEMERGENCY
(skip this section if there are no changes)
Date of Emergency Intervention (mmddyyyy): Indicate the type of emergency intervention:
m m (e.g., emergency room visit, crisis stabilization unit)
O Physical Health Related O Mental Health /Substance Abuse Related
COUNTYQUESTIONS
Date of County Use Field #1 Change (mmddyyyy): Indicate NEW County Use Field #1
m m - 1 1 � Ll I T-1 I I I I I I I I I I I
Date of County Use Field #2 Change (mmddyyyy): Indicate NEW County Use Field #2
m m
Date of County Use Field #3 Change (mmddyyyy): Indicate NEW County Use Field #3
m m
Page 5 of 5
Exhibit Q C T L I F O R N I G D F P G R T M F N T OF
Page 27of30 ULT KET
Mental Health AD 612/06
6/2/06
FULL SERVICE PARTNERSHIP
Adult Key Event Tracking Form
FOR AGES 26-59 YEARS
PARTNERSHIP INFORMATION
County Number CSI County Client Number Unique County ID (optional)
m
Partner's First Name Partner's Last Name
I I � � I I I � � I I I � I I FFF� I I � � � � � � � � � � � � � El
Date Completed (mmddyyyy) Partner's Date of Birth (mmddyyyy)
CHANGE IN m m m m
ADMINISTRATIVE INFORMATION
changes)
Is the partner CURRENTLY involved in:
YES NO Date of AB2034 change (mmddyyyy):
AB2034 O O m m
YES NO Date of Governor's Homeless Initiative (GHI) change (mmddyyyy):
Governor's Homeless Initiative (GHI) O O m m
Date of Provider Site ID Change (mmddyyyy): NEW Provider Site ID
m m
Date of Full Service Partnership
Program ID Change (mmddyyyy): NEW Full Service Partnership Program ID
m m
Date of Partnership Service Coordinator ID
Change (mmddyyyy): NEW Partnership Service Coordinator ID
m m
Date of Partnership Status Change (mmddyyyy): Indicate new partnership status:
m m O Discontinuation/Interruption of Full O Reestablishment of
Service Partnership and/or Full Service Partnership and/or
community services/program community services/program
(indicate reason below)
If there is a DISCONTINUATION/INTERRUPTION of Full Service Partnership and/or community services/program,
indicate the reason (mark one):
O Target population criteria are not met.
O Partner decided to discontinue Full Service Partnership participation after partnership established.
O Partner moved to another county/service area.
O After repeated attempts to contact partner, partner cannot be located.
O Community services/program interrupted - Partner's circumstances reflect a need for residential/institutional mental
health services at this time (such as IMD, MHRC, State Hospital).
O Community services/program interrupted - Partner will be serving jail/prison sentence.
O Partner has successfully met his/her goals such that discontinuation of Full Service Partnership is appropriate.
O Partner is deceased.
Page 1 of 4
Exhibit Q
Page 28 of 30 ADULT KET
6/2/06
RESIDENTIAL - includes • and incarceration
(skip this section if there are no changes)
Date of Residential Status Change (mmddyyyy): m m
Indicate the new residential status (mark one):
GENERAL LIVING ARRANGEMENT RESIDENTIAL PROGRAM
In an apartment or house alone/with spouse/partner/minor children/other
dependents/roommate-must hold lease or share in rent/mortgage O Licensed Residential Treatment(includes crisis,short-term,
O With one or both biological/adoptive parents long-term,substance abuse,dual diagnosis residential programs)
O With adult family member(s)other than parents Q Skilled Nursing Facility(physical)
O Single Room Occupancy(must hold lease) Q Skilled Nursing Facility(psychiatric)
SHELTER/HOMELESS O Long-Term Institutional Care(IMD, MHRC)
O Emergency Shelter/Temporary Housing(includes people living with friends but
paying no rent) JUSTICE PLACEMENT
O Homeless(includes people living in their cars) O Jail
SUPERVISED PLACEMENT O Prison
Q Unlicensed but supervised individual placement(includes paid caretakers, O Other
personal care attendants,etc.)
Q Assisted Living Facility O Unknown
Q Unlicensed but supervised congregate placement(includes group living homes,
sober living homes)
O Licensed Community Care Facility(Board and Care)
HOSPITAL
Q Acute Medical Hospital
Q Acute Psychiatric Hospital/Psychiatric Health Facility(PHF)
O State Psychiatric Hospital
(skipEDUCATION
this sectionnochanges)
GRADE LEVEL INFORMATION
Date of Grade Level Completion (mmddyyyy)
m m
Level of education completed:
O No High School Diploma/ No GED O AA degree O Less than 2 years graduate school
O GED Coursework O Technical/Vocational Degree O Master's degree (e.g., M.A., M.S.W.)
O High School Diploma/GED O 3-4 years college O 3-4 years graduate training
O Less than 2 years college/ O Bachelor's Degree (B.A., B.S.) O Doctoral degree (e.g., M.D., Ph.D.)
Some Technical/Vocational Training
EDUCATIONAL SETTING INFORMATION
Date of Educational Setting Change (mmddyyyy) Indicate the new educational setting(s) (mark all that apply):
mm O Not in school of any kind O Community College/4 year College
O High School /Adult Education O Graduate School
O Technical/Vocational School O Other
If stopping school, did the partner complete a class and/or program? O Yes O No
Does one of the partner's current recovery goals include any kind of education at this time? O Yes O No
Page 2 of 4
Exhibit Q
Page 29 of 30 ADULT KET
6/2/06
(skip this section if there are no EMPLOYMENT
-
Date of Employment Change (mmddyyyy): [11
[11
CURRENT EMPLOYMENT
Indicate the partner's employment status... AVERAGE
HOURS/WEEK HOURLY WAGE
Competitive Employment: m � .m
Paid employment in the community in a position that is also
open to individuals without a disability.
Supported Employment: m .m
Competitive Employment(see above)with ongoing on-site or
off-site job-related support services provided.
Transitional Employment/Enclave: m $ � m Paid jobs in the community that are 1)open only to individuals
with a disability AND 2)are either time-limited for the purpose of
moving to a more permanent job OR are part of a group of
disabled individuals who are working as a team in the midst of
teams of non-disabled individuals who are performing the same
work.
Paid In-House Work(Sheltered Workshop/Work Experience/Agency-Owned Business):
Paid jobs open only to program participants with a disability. A
Sheltered Workshop usually offers sub-minimum wage work in a
simulated environment. A Work Experience (Adjustment)
Program within an agency provides exposure to the standard
expectations and advantages of employment. An
Agency-Owned Business serves customers outside the agency
and provides realistic work experiences and can be located at
the program site or in the community.
Non-paid (Volunteer)Work Experience: m
Non-paid (volunteer)jobs in an agency or volunteer work in the
community that provides exposure to the standard expectations
of employment.
Other Gainful/Employment Activity:
Any informal employment activity that increases the partner's
income(e.g., recycling, gardening, babysitting)OR participation
in formal structured classes and/or workshops providing
instruction on issues pertinent to getting a job. (Does NOT
include such activities as panhandling or illegal activities such
as prostitution).
Check here if the partner is not employed at this time: ❑
Does one of the partner's current recovery goals include any kind of employment at this time? O Yes O No
Page 3 of 4
Exhibit Q
Page 30 of 30 ADULT KET
6/2/06
LEGAL • •
(skip this section if there are no . -
ARREST INFORMATION
Date Partner Arrested (mmddyyyy): m m
PROBATION / PAROLE INFORMATION
Date of Probation Status Change (mmddyyyy): Indicate new probation status:
m m I I I 1
O Removed From Probation O Placed on Probation
Date of Parole Status Change (mmddyyyy): Indicate new parole status:
m m I I I 1 O Removed From Parole O Placed on Parole
CONSERVATORSHIP / PAYEE INFORMATION
Date of Conservatorship
Status Change (mmddyyyy): Indicate new conservatorship status:
mm - F1 I 1 O Removed from conservatorship O Placed on conservatorship
Date of Payee Status Change (mmddyyyy): Indicate new payee status:
mm O Removed from payee status O Placed on payee status
INTERVENTIONEMERGENCY
(skip this section if there are no changes)
Date of Emergency Intervention (mmddyyyy): Indicate the type of emergency intervention:
m m (e.g., emergency room visit, crisis stabilization unit)
O Physical Health Related O Mental Health / Substance Abuse Related
COUNTYQUESTIONS
Date of County Use Field #1 Change (mmddyyyy): Indicate NEW County Use Field #1
m m
Date of County Use Field #2 Change (mmddyyyy): Indicate NEW County Use Field #2
m m
Date of County Use Field #3 Change (mmddyyyy): Indicate NEW County Use Field #3
m mLl I T-1 I I I I I I I I I I
Page 4 of 4