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Agreement No.15-189
AGREEMENT
This Agreement is made and entered into this IC\"f., day of '°'~""it' 2015, by and
between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
referred to as "COUNTY", and FAMILIESFIRST, INC., dba EMQ FAMILIESFIRST, a non-
profit corporation, whose address is 251 Llewellyn A venue, Campbell, California 95008-1940,
hereinafter referred to as "CONTRACTOR".
WITNE SSE TH:
WHEREAS, Senate Bill 163, Chapter 795, Statutes of 1997 (Welfare and Institutions Code
Sections 18250, et seq.) authorizes California counties to provide children with service alternatives to
group home care through the development of expanded family-based services programs, including
"wraparound" services, where services are wrapped around a child living with his or her birthparent,
relative, adoptive parent, licensed or certified foster parent, or guardian and are built on the strengths
of each eligible child and family and tailored to address their unique and changing needs; and
WHEREAS, COUNTY, through its Department of Social Services (DSS), is in need of a
qualified agency to provide Senate Bill 163 (SB 163) Wraparound services and Therapeutic Foster
Care services (TFC) to SB 163 eligible children and their families involved in the Child Welfare
Services (CWS) system; and
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is a Mental
Health Plan (MHP) as defined in Title 9 of the California Code of Regulations (CCR), Section
1810.226; and
WHEREAS, CONTRACTOR is qualified and willing to provide said services pursuant to the
terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the
parties hereto agree as follows:
1. SERVICES
A. CONTRACTOR shall perform all services and fulfill all responsibilities as set
27 forth in Exhibit A, "Summary of Services", attached hereto and by this reference incorporated herein.
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1 -County of Fresno
Fresno, CA
1 B. CONTRACTOR shall also perform all services and fulfill all responsibilities as
2 specified in COUNTY's Request for Proposal (RFP) No. 952-5322 dated January 5, 2015 and
3 Addendum No. One (I) to COUNTY's RFP No. 952-5322 dated January 22, 2015, herein collectively
4 referred to as COUNTY's Revised RFP, and CONTRACTOR's Response to said Revised RFP dated
5 February 11, 2015; all incorporated herein by reference and made part of this Agreement. In the event
6 of any inconsistency among these documents, the inconsistency shall be resolved by giving
7 precedence in the following order of priority: (1) to this Agreement, including all Exhibits; (2) to the
8 Revised RFP; and (3) to CONTRACTOR's Response to the Revised RFP. A copy ofCOUNTY's
9 Revised RFP No.952-5322 and CONTRACTOR's Response thereto shall be retained and made
10 available during the term of this Agreement by COUNTY's DSS Administrative unit.
11 C. It is acknowledged by all parties hereto that COUNTY's DSS and DBH
12 Administrative Units shall monitor the Mental Health Services provided by the CONTRACTOR.
13 D. CONTRACTOR shall participate in periodic workgroup meetings including staff
14 from COUNTY's DSS and DBH Administrative units. The meetings shall be held monthly, or as
15 needed, to discuss program requirements, data reporting, outcomes measurement, training, policies
16 and procedures, and overall program operations.
17 E. It is acknowledged by all parties hereto that upon execution of this Agreement,
18 CONTRACTOR's service site shall be 1630 E. Shaw Avenue, Suite 150, Fresno, CA, 93710. Any
19 change to CONTRACTOR's location of the service site may be made only upon thirty (30) days
2 0 advance written notification to COUNTY's DSS Director and upon written approval from the
21 COUNTY' s DSS Director, or designee.
22 F. CONTRACTOR shall maintain requirements as an organizational provider
2 3 throughout the term of this Agreement, as further defined herein. If for any reason, this status is not
2 4 maintained, the COUNTY may terminate this Agreement pursuant to Section 3 of this Agreement.
25 G. CONTRACTOR agrees that prior to providing services under the terms and
2 6 conditions of this Agreement, it shall have appropriate staff hired and in place for program services
2 7 and operations or COUNTY may, in addition to other remedies it may have, suspend referrals or
2 8 terminate this Agreement in accordance with Section 3 of this Agreement.
2 -County of Fresno
Fresno, CA
1 2. TERM
2 This Agreement shall become effective on the I st day of July, 2015 and shall terminate
3 on the 30th day of June, 2016.
4 This Agreement shall be extended for two (2) additional twelve ( 12) month periods,
5 based upon the evaluation and satisfactory outcomes performance of the CONTRACTOR. If
6 CONTRACTOR has met the performance standards as specified within this Agreement, the
7 COUNTY's DSS Director shall send a letter of renewal to the CONTRACTOR, upon the same terms
8 and conditions herein set forth. A written notice of non-renewal may be given by either COUNTY or
9 CONTRACTOR or COUNTY's DSS Director, or designee, not later than sixty (60) days prior to the
10 close of the current Agreement term.
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3. TERMINATION
A. Non-Allocation of Funds -the terms of this Agreement, and the services to be
13 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
14 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
15 terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
16 B. Breach of Contract -COUNTY may immediately suspend or terminate this
1 7 Agreement in whole or in part, where in the determination of COUNTY there is:
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An illegal or improper use of funds;
A failure to comply with any term of this Agreement;
A substantially incorrect or incomplete report submitted to COUNTY;
21 4) Improperly performed service.
2 2 In no event shall any payment by COUNTY constitute a waiver by COUNTY of
2 3 any breach of this Agreement or any default which may then exist on the part of CONTRACTOR.
2 4 Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
25 breach or default. COUNTY shall have the right to demand of CONTRACTOR the repayment to
2 6 COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of
27 COUNTY were not expended in accordance with the terms of this Agreement. CONTRACTOR shall
2 8 promptly refund any such funds upon demand or, at COUNTY's option, such repayment shall be
- 3 County of Fresno
Fresno, CA
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deducted from future payments owing to CONTRACTOR under this Agreement.
C. Without Cause -Under circumstances other than those set forth above, this
Agreement may be terminated by CONTRACTOR or COUNTY or COUNTY's DSS Director, or
designee, upon the giving of sixty (60) days advance written notice of an intention to terminate the
Agreement.
4. COMPENSATION
A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to
8 receive compensation in accordance with Exhibit B, "Budget," attached hereto and by this reference
9 incorporated herein. Mandated travel shall be reimbursed based on actual expenditures and mileage
10 reimbursement shall be at CONTRACTOR's adopted rate per mile, not to exceed the IRS published
11 rate. In no event shall the administrative costs exceed the total amounts identified in Exhibit B.
12 Payment shall be made upon certification or other proof satisfactory to COUNTY' s DSS that services
13 have actually been performed by CONTRACTOR as specified in this Agreement.
14 For each twelve (12) month period of this Agreement, in no event shall all actual
15 services performed under this Agreement be in excess of Four Million, Five Hundred Thousand, and
16 No/100 Dollars ($4,500,000.00). The cumulative total of this Agreement for the three (3) year period
1 7 for both specialty mental health Medi-Cal and Non-Medi-Cal billable services shall not be in excess of
18 Thirteen Million, Five Hundred Thousand, and No/I 00 Dollars ($13,500,000.00). It is understood that
19 all expenses incidental to CONTRACTOR's performance of services under this Agreement shall be
20 borne by CONTRACTOR.
21 Except as provided below regarding State payment delays, payments by
22 COUNTY shall be in arrears, for services provided during the preceding month, within forty-five (45)
23 days after receipt, verification and approval ofCONTRACTOR's invoices by COUNTY's DSS and/or
24 DBH, as applicable. If CONTRACTOR should fail to comply with any provision of this Agreement,
2 5 COUNTY shall be relieved of its obligation for further compensation. All final claims and/or any
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4 County of Fresno
Fresno, CA
1 final budget modification requests shall be submitted by CONTRACTOR within sixty (60) days
2 following the final month of service for which payment is claimed. No action shall be taken by
3 COUNTY on claims submitted beyond the sixty (60) day closeout period. Any compensation which
4 is not expended by CONTRACTOR pursuant to the terms and conditions of this Agreement shall
5 automatically revert to COUNTY.
6 The services provided by CONTRACTOR under this Agreement are funded in
7 whole or in part by the State of California. In the event that funding for these services is delayed by
8 the State Controller, COUNTY may defer payment to CONTRACTOR. The amount of the deferred
9 payment shall not exceed the amount of funding delayed by the State Controller to COUNTY. The
10 period of time of the deferral by COUNTY shall not exceed the period of time of the State
11 Controller's delay of payment to COUNTY plus forty-five (45) days.
12 B. MHP Specialty Mental Health Services: Subject to the Claims and Payment
13 Processing requirements set forth in Section 5 herein, COUNTY's DBH agrees to reimburse
14 CONTRACTOR for rendering MHP Covered Services to clients in the manner detailed in this Section
15 4B. During the entire term of this Agreement, payment for CONTRACTOR's services will be
16 reimbursed at the rates included in the COUNTY's Organizational Provider Transition Fee schedule as
1 7 follows:
18 Mental Health Services, Collateral, Intensive Home Based Services (IHBS) Rehab and
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Court Reports and Court Appearances (per minute)
Case Management and
Intensive Care Coordination (ICC) Case Management (per minute)
Crisis Intervention (per minute)
Medication Support (per minute)
$2.61
$2.02
$3.88
$4.82
2 4 Said reimbursement rates shall be payment in full, subject to the cost settlement
2 5 process identified in Section 13, third party liability, and client share of costs for the specialty mental
2 6 health services to a client. CONTRACTOR shall be knowledgeable of all possible MediCal billable
2 7 services, in order to maximize the Federal Financial Participation (FFP) reimbursement for
2 8 MediCal/Medicare eligible services. If clients have other health insurance coverage, CONTRACTOR
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Fresno, CA
1 must bill any such third-party payers, including Medicare, before requesting payment from the
2 COUNTY. In the event there is such third party coverage for the covered services provided,
3 COUNTY shall have no obligation to make any payment to CONTRACTOR. Where applicable,
4 CONTRACTOR shall submit claims to the COUNTY along with a copy of the Medi-Cal denial letter
5 or explanation of benefits or other third-party payer denial letter or explanation of benefits within
6 thirty (30) days of the date of such denial. Additionally, by the execution of this Agreement, there is
7 no guarantee made by COUNTY to CONTRACTOR that any MHP Covered Services shall be
8 provided to any client.
9 COUNTY shall not make payment for services rendered to MHP clients which
10 are, in the opinion of COUNTY, determined to be not medically necessary or which have not been
11 authorized for reimbursement by COUNTY MHP. CONTRACTOR understands and agrees that
12 services are not MHP Covered Services unless authorized in advance for reimbursement by COUNTY
13 MHP.
14 Unless the client has other health insurance coverage, CONTRACTOR shall
15 look only to COUNTY for compensation for MHP Covered Services and, with the exception of
16 authorized share of cost payments and/or non-covered services, shall at no time seek compensation
1 7 from clients.
18 C. Non-MHP Mental Health Services and Other Wraparound Services:
19 Subject to the Claims and Payment Processing requirements set forth in Section
2 O 5 herein, COUNTY's DSS agrees to reimburse CONTRACTOR for rendering Non-MHP Mental
21 Health Services and Other Wraparound Services in the manner detailed in subsections CI and C2
22 herein. During the entire term of this Agreement, payment for Non-MHP Mental Health Services and
2 3 Other Wraparound Services shall be reimbursed at the following rates:
24 L Reimbursement for Non-MHP Mental Health Services shall be made at
2 5 the COUNTY's Organizational Provider Transition Fee schedule as follows:
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Non Medi-Cal billable service (per unit) $1.10
Reimbursement for Other Wraparound Services shall be made by
28 COUNTY's DSS to CONTRACTOR for actual costs incurred by CONTRACTOR to deliver Other
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Fresno, CA
1 Wraparound Services to clients. Allowable reimbursement costs are limited to those costs detailed in
2 Exhibit B.
3 In no event shall services performed by CONTRACTOR for Non-MHP Mental
4 Health Services and Other Wraparound Services be in excess of One Million, One Hundred Twenty-
5 Five Thousand, and No/100 Dollars ($1,125,000.00), for any twelve (12) month period: July 1, 2015
6 through June 30, 2016; July 1, 2016 through June 30, 2017; or July 1, 2017 through June 30, 2018.
7 In no event shall the maximum reimbursements for Non-MHP Mental Health
8 Services and Other Wraparound Services from July 1, 2015 through June 30, 2018 exceed Three
9 Million, Three Hundred Seventy-Five Thousand, and No/100 Dollars ($3,375,000.00).
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D. It is understood that all expenses incidental to CONTRACTOR's performance of
services under this Agreement shall be borne by CONTRACTOR. Payments by COUNTY shall be
in arrears, for services provided during the preceding month, within forty-five (45) days after the
receipt and verification ofCONTRACTOR's invoice by COUNTY. If CONTRACTOR should fail
to comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for
future compensation.
E. COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
All final claims, including actual costs per units, and/or any final budget
modification requests shall be submitted by CONTRACTOR within sixty (60) days following the
final month of service for which payment is claimed. No action shall be taken by COUNTY on
claims submitted beyond the sixty ( 60) day closeout period. Any compensation which is not
expended by CONTRACTOR pursuant to the terms and conditions of this Agreement shall
automatically revert to COUNTY.
F. CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR's deficiency discovered through the State
audit process and COUNTY utilization review during the course of this Agreement. At COUNTY's
election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon
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Fresno, CA
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notification or shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR
shall not receive reimbursement for any units of services rendered that are disallowed or denied by
the Fresno County Mental Health Plan (MHP) utilization review process or through State Department
of Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients.
5. INVOICING/BILLING
A. CONTRACTOR shall invoice COUNTY in arrears by the twentieth (20th ) of
7 each month for actual expenses incurred and services rendered in the previous month to the
8 distribution list of COUNTY'S DSS and DBH Staff as provided in Exhibit A, in the "Data and
9 Reporting" subsection. Complete invoices shall include, Exhibit C, "Invoice Summary and Invoice
10 Detail", attached hereto and by this reference incorporated herein, including: 1) Invoice Summary, 2)
11 Invoice Detail of Medi-Cal Billable Items, 3) Invoice Detail of Non-Medi-Cal Billable Items, and 4)
12 Invoice Detail of Flex Fund Billable Items; as well as Exhibit D, "Cost Allocation Detail Tracking",
13 attached hereto and by this reference incorporated herein, including: l) Cost Allocation Summary, 2)
14 Combined Medi-Cal and Non Medi-Cal, 3) Medi-Cal, and 4) Non Medi-Cal. If any document is
15 missing, invoicing will be considered incomplete. At the discretion of COUNTY' s DSS Director, or
16 designee, if an invoice is incorrect or is otherwise not in proper form or substance, COUNTY's DSS
1 7 Director, or designee, shall have the right to withhold payment as to only that portion of the invoice
18 that is incorrect or improper after five (5) days prior notice to CONTRACTOR. CONTRACTOR
19 agrees to continue to provide services for a period of ninety (90) days after notification of an incorrect
2 0 or improper invoice. If after the ninety (90) day period, the invoice(s) is still not corrected to
21 COUNTY's DSS satisfaction, COUNTY's DSS Director, or designee, may elect to terminate this
2 2 Agreement, pursuant to the termination provisions stated in Section 3 of this Agreement. In addition,
2 3 for invoices received ninety (90) days after the expiration of each term of this Agreement or
2 4 termination of this Agreement, at the discretion ofCOUNTY's DSS Director, or designee,
2 5 COUNTY's DSS shall have the right to deny payment of any additional invoices received.
26 B. After CONTRACTOR renders services to referred clients, CONTRACTOR will
2 7 submit electronic billing for services directly into COUNTY's billing system (A VAT AR) within ten
2 8 ( I 0) calendar days from the date services were rendered for all clients, including those eligible for
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Fresno, CA
1 Medi-Cal as well as those that are not eligible for Medi-Cal. COUNTY must pay CONTRACTOR
2 before submitting a claim to DHCS for Federal Financial Participation (FFP) reimbursement for
3 specialty mental health services provided to Medi-Cal eligible clients. DHCS FFP reimbursement for
4 Medi-Cal services is based on public expenditures certified by the CONTRACTOR. CONTRACTOR
5 must submit a signed certified public expenditure report in the monthly invoice. DHCS expects the
6 claim for reimbursement to equal the amount the COUNTY paid to CONTRACTOR for the services
7 rendered less any funding sources not eligible for Federal reimbursement.
8 C. Exhibit D, "Cost Allocation Detail Tracking", will also serve for the COUNTY
9 to certify the public funds expended for purposes of claiming federal reimbursement for the cost of
10 Medi-Cal services and activities.
11 D. CONTRACTOR must report all third party collections from other funding
12 sources for Medicare, private insurance, client private pay, or any other third party along with each
13 monthly invoice.
14 E. CONTRACTOR will remit annually within ninety (90) days from June 30, a
15 schedule to provide the required information on published charges (PC) for all authorized services.
16 The published charges listing will serve as a source document to determine their usual and customary
1 7 charge prevalent in the public mental health sector that is used to bill the general public, insurers or
18 other non-Medi-Cal third party payers during the course of business operations.
19 F. CONTRACTOR shall submit a monthly staffing report that identifies all direct
2 0 service and support staff, applicable licensure/certifications, and full-time hours worked to be used as
21 a tracking tool to determine if CONTRACTOR's program is staffed according to the Agreement
2 2 requirements.
23 G. CONTRACTOR must maintain such financial records for a period of seven (7)
2 4 years until the dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be
2 5 responsible for any disallowances related to inadequate documentation.
26 H. CONTRACTOR shall be responsible for collection and managing data in a
2 7 manner to be determined by DHCS and the MHP in accordance with applicable rules and regulations.
2 8 COUNTY electronic billing systems are a critical source of information for purposes of monitoring
9 County of Fresno
Fresno, CA
1 and obtaining reimbursement. CONTRACTOR must attend COUNTY's Business Office training on
2 equipment reporting for assets, intangible and sensitive minor assets, AV AT AR electronic claiming
3 module, and related cost reporting.
4 I. CONTRACTOR must provide all necessary data to allow the COUNTY to bill
5 Medi-Cal, and any other third-party source, for services and meet State and Federal reporting
6 requirements. The necessary data can be provided by a variety of means, including but not limited to:
7 1) direct data entry into COUNTY's information system, AVATAR, 2) providing an electronic file
8 compatible with COUNTY's information system, or 3) integration between COUNTY's information
9 system and CONTRACTOR's information system(s).
10 J. If a Medi-Cal client has dual coverage, such as other health coverage (OHC) or
11 Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a
12 payment/denial or have validation of claiming with no response ninety (90) days after the claim was
13 mailed before the services can be entered into AV A TAR. CONTRACTOR must report all third party
14 collection for Medicare, third party or client in the monthly invoice and in the cost report that is
15 required to be submitted. A copy of explanation of benefits of CWM 1500 is required as
16 documentation. CONTRACTOR must comply with all laws and regulations governing Medicare
17 program, including, but not limited to: 1) the requirement of the Medicare Act, 42 USC Section 1395
18 et seq; and 2) the regulation and rules promulgated by the Centers for Medicare and Medicaid Services
19 as they related participation, coverage and claiming reimbursement. CONTRACTOR will be
2 0 responsible for compliance as of the effective date of each federal, state or local law or regulation
2 1 specified.
22 K. Data entry shall be the responsibility of the CONTRACTOR. The data for
23 billing must be reconciled by the CONTRACTOR to the monthly invoice for payment. COUNTY
2 4 shall monitor the number and dollar amount of services entered into AV AT AR. Any and all audit
2 5 exceptions resulting from the provision and billing of Medi-Cal services by CONTRACTOR shall be
2 6 the sole responsibility of the CONTRACTOR. CONTRACTOR will comply with all applicable
2 7 policies, procedures, directives and guidelines regarding the use of COUNTY' s AV AT AR billing
28 system.
10 County of Fresno
Fresno, CA
1 L. Medi-Cal Certification and Mental Health Plan Compliance
2 CONTRACTOR will establish and maintain Medi-Cal certification or become
3 certified within ninety (90) days of the start of this Agreement through the COUNTY and DHCS to
4 provide reimbursable services to Medi-Cal eligible clients. In addition, CONTRACTOR shall work
5 with the COUNTY's DBH Managed Care and Business Office to execute the process if not currently
6 certified by COUNTY for credentialing of staff. Service location must be approved by the
7 COUNTY's DSS. During this process the CONTRACTOR will obtain a legal entity number
8 established by DHCS, a requirement for maintaining organizational provider status throughout the
9 term of this Agreement. CONTRACTOR will be required to become Medi-Cal certified prior to
1 O providing services to Medi-Cal eligible clients and seeking reimbursement in COUNTY' s billing
11 system. CONTRACTOR will not be reimbursed by COUNTY for any Medi-Cal services rendered
12 prior to certification.
13 Medi-Cal billing shall be in accordance with the COUNTY's MHP.
14 CONTRACTOR must comply with Exhibit E, "Fresno County Mental Health Plan Compliance
15 Program and Contractor Code of Conduct and Ethics", attached hereto and by this reference
16 incorporated herein.
1 7 Medi-Cal can be billed for direct specialty mental health services of unlicensed
18 staff as long as the individual is approved as an organizational provider by the COUNTY's MHP, is
19 supervised by licensed staff, works within his/her scope and only bills Medi-Cal for allowable
2 0 specialty mental health services.
21 It is understood that each claim is subject to audit for compliance with Federal
2 2 and State regulations, and that COUNTY may be making payments in advance of said review. In the
2 3 event that a Medi-Cal billable service is disapproved, COUNTY may, at its sole discretion, withhold
2 4 compensation or set off from other payments due the amount of said disapproved services.
2 5 CONTRACTOR shall be responsible for audit exceptions to ineligible dates of services or incorrect
2 6 application of utilization review requirements.
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6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under
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Fresno, CA
1 this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
2 CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
3 independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
4 employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no
5 right to control or supervise or direct the manner or method by which CONTRACTOR shall perform
6 its work and function. However, COUNTY shall retain the right to administer this Agreement so as to
7 verify that CONTRACTOR is performing its obligations in accordance with the terms and conditions
8 thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the
9 rules and regulations, if any, of governmental authorities having jurisdiction over matters which are
10 directly or indirectly the subject of this Agreement.
11 Because of its status as an independent contractor, CONTRACTOR shall have
12 absolutely no right to employment rights and benefits available to COUNTY employees.
13 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees
14 all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and
15 save COUNTY harmless from all matters relating to payment ofCONTRACTOR's employees,
16 including compliance with Social Security, withholding, and all other regulations governing such
17 matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be
18 providing services to others unrelated to COUNTY or to this Agreement.
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7. MODIFICATION
A. Any matters of this Agreement may be modified from time to time by the written
consent of all the parties without, in any way, affecting the remainder.
B. Changes to line items identified in Exhibit B, in an amount not to exceed ten
2 3 percent ( I 0%) of the total maximum compensation of said line item, may be made with the written
2 4 approval of COUNTY's DSS Director, or designee, and CONTRACTOR. Budget line item changes
2 5 shall not result in any change to the maximum compensation amount payable to CONTRACTOR, as
2 6 stated herein.
C. CONTRACTOR hereby agrees that changes to the compensation under this 27
28 Agreement may be necessitated by a reduction in funding from State and/or Federal sources.
12 County of Fresno
Fresno, CA
1 COUNTY's DSS Director, or designee, may modify the maximum compensation depending on State
2 and Federal funding availability, as stated in Section 4 in this Agreement. CONTRACTOR further
3 understands that this Agreement is subject to any restrictions, limitations or enactments of all
4 legislative bodies which affect the provisions, term or funding of this Agreement in any manner.
5 8. NON-ASSIGNMENT
6 Neither party shall assign, transfer or subcontract this Agreement nor their rights or
7 duties under this Agreement without the prior written consent of the other party.
8 9. HOLD-HARMLESS
9 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
1 O defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
11 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
12 COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers,
13 agents or employees under this Agreement, and from any and all costs and expenses, including
14 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
15 person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
16 of CONTRACTOR, its officers, agents or employees under this Agreement. In addition,
1 7 CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local audit
18 exceptions resulting from noncompliance herein on the part of the CONTRACTOR.
19 10. INSURANCE
2 0 Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or
21 any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the
2 2 following insurance policies throughout the term of this Agreement:
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A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million
Dollars ($2,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations,
product liability, contractual liability, Explosion, Collapse, and Underground
(XCU), fire legal liability or any other liability insurance deemed necessary
because of the nature of the Agreement.
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Fresno, CA
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Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a
combined single limit of Five Hundred Thousand Dollars ($500,000). Coverage
should include owned and non-owned vehicles used in connection with this
Agreement.
Personal Property
CONTRACTOR shall maintain a policy of insurance for all risk personal
property coverage which shall be endorsed naming the County of Fresno as an
additional loss payee. The personal property coverage shall be in an amount that
will cover the total of the County purchased and owned property, at a minimum,
as discussed in Section 21 of this Agreement.
Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., M.F.C.T.) in providing services, Professional Liability Insurance with
limits of not less than One Million Dollars ($1,000,000) per occurrence, Three
Million Dollars ($3,000,000) annual aggregate. CONTRACTOR agrees that it
shall maintain, at its sole expense, in full force and effect for a period of three (3)
years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
Sexual Abuse / Molestation Liability
Sexual Abuse / Molestation Liability Insurance (including but not limited to
corporal punishment liability, sexual abuse and molestation liability, and child
abduction liability) with limits of not less than One Million Dollars ($1,000,000)
per occurrence, Two Million Dollars ($2,000,000) annual aggregate. This policy
shall be issued on a per occurrence basis.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
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1 concerned. Such coverage for additional insured shall apply as primary insurance and any other
2 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
3 excess only and not contributing with insurance provided under CONTRACTOR's policies herein.
4 This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance
5 written notice given to COUNTY.
6 Within thirty (30) days from the date CONTRACTOR signs this Agreement,
7 CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of
8 the foregoing policies, as required herein, to the County of Fresno, DSS, PO BOX 1912, Fresno,
9 California, 93 718-1912, Attention: Tanimara Puente, stating that such insurance coverages have been
10 obtained and are in full force; that the County of Fresno, its officers, agents and employees will not be
11 responsible for any premiums on the policies; that such Commercial General Liability insurance
12 names the County of Fresno, its officers, agents and employees, individually and collectively, as
13 additional insured, but only insofar as the operations under this Agreement are concerned; that such
14 coverage for additional insured shall apply as primary insurance and any other insurance, or self-
15 insurance, maintained by COUNTY, its officers, agents and employees, shall be excess only and not
16 contributing with insurance provided under CONTRACTOR's policies herein; and that this insurance
1 7 shall not be cancelled or changed without a minimum of thirty (30) days advance, written notice given
18 to COUNTY.
19 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
2 0 herein provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
21 Agreement upon the occurrence of such event.
2 2 All policies shall be with admitted insurers licensed to do business in the State of
2 3 California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
2 4 of A FSC VII or better.
25 11. LICENSES/CERTIFICATES
2 6 Throughout the term of this Agreement, CONTRACTOR and CONTRACTOR's staff
2 7 shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions
2 8 necessary for the provision of the services hereunder and required by the laws and regulations of the
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1 United States of America, State of California, the County of Fresno, and any other applicable
2 governmental agencies. CONTRACTOR shall notify COUNTY immediately in writing of its inability
3 to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions
4 irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR and
5 CONTRACTOR's staff shall comply with applicable laws, rules or regulations, as may now exist or
6 be hereafter changed.
7 12. RECORDS
8 CONTRACTOR shall maintain records in accordance with COUNTY's Exhibit F,
9 "Documentation Standards for Client Records", attached hereto and by this reference incorporated
10 herein. During site visits, COUNTY shall be allowed to review records of services provided,
11 including the goals and objectives of the treatment plan, and how the therapy provided is achieving the
12 goals and objectives.
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13. REPORTS
A. Cost Report
15 CONTRACTOR agrees to submit a complete and accurate detailed costs report
16 on an annual basis for each fiscal year ending June 30 th in the format prescribed by DHCS for the
1 7 purposes of Short Doyle Medi-Cal reimbursements and total costs for programs. The cost report will
18 be the source document for several phases of settlement with the DHCS for the purposes of Short
19 Doyle Medi-Cal reimbursement. CONTRACTOR shall reports costs under their approved legal entity
2 0 number established during the Medi-Cal certification process. The information provided applies to
21 CONTRACTOR for program related costs for services rendered to Medi-Cal and non Medi-Cal.
2 2 CONTRACTOR will remit a schedule to provide the required information on published charges (PC)
2 3 for all authorized services. The report will serve as a source document to determine their usual and
2 4 customary charge prevalent in the public mental health sector that is used to bill the general public,
25 insurers or other non-Medi-Cal third party payers during the course of business operations.
2 6 CONTRACTOR must report all collections for Medi-Cal/Medicare services and collections.
2 7 CONTRACTOR shall also submit with the cost report a copy of the CONTRACTOR's general ledger
2 8 that supports revenues and expenditures and reconciled detailed report of reported total units of
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1 services rendered under this Agreement to the units of services reported by CONTRACTOR to
2 COUNTY' s data system.
3 Cost Reports must be submitted to the COUNTY a hard copy with signed cover
4 letter and electronic copy of completed DHCS cost report form along with requested support
5 documents following each fiscal year ending June 30th • During the month of September of each year
6 this Agreement is effective, COUNTY will issue instructions of the annual cost report which indicates
7 the training session, DHCS cost report template worksheets, and deadlines to submit as determined by
8 the State annually. CONTRACTOR shall remit the hard copy of the cost report to County of Fresno,
9 Attention: Cost Report Team, PO BOX 45003, Fresno CA 93718. CONTRACTOR shall remit
10 electronic copies or any inquiries to DBHcostreportteam@co.fresno.ca.us and carbon copy (cc)
11 tbeatrez@co.fresno.ca.us.
12 All Cost Reports must be prepared in accordance with Generally Accepted
13 Accounting Principles (GAAP) and Welfare and Institution Code§§ 565I(a)(4), 5664(a), 5705(b)(3)
14 and 5718(c). Unallowable costs such as lobby or political donations must be deducted on the cost
15 report and invoice reimbursements.
16 If the CONTRACTOR does not submit the cost report by the deadline, including
17 any extension period grant by the COUNTY, the COUNTY may withhold payments of pending
18 invoicing under compensation until the cost report has been submitted and clear COUNTY desk audit
19 for completeness.
20 B. Settlements with State Department of Health Care Services (DHCS)
21 During the term on this Agreement and thereafter, COUNTY and
2 2 CONTRACTOR agree to settle dollar amounts disallowed or settled in accordance with DHCS and
2 3 COUNTY audit settlement findings related to the Medi-Cal and realignment reimbursements.
2 4 CONTRACTOR will participate in the several phases of settlements between
2 5 COUNTY /CONTRACTOR and DHCS. The phases are initial cost reporting for settlement,
2 6 settlement according to State reconciliation of records for paid Medi-Cal services and audit settlement-
2 7 DHCS audit: l) initial cost reporting after an internal review by COUNTY, the COUNTY files cost
2 8 report with DHCS on behalf of COUNTRACTOR' s legal entity for the fiscal year; 2) Settlement -
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1 State reconciliation of records for paid Medi-Cal services, approximately eighteen (18) to thirty-six
2 (36) months following the State close of the fiscal year, DHCS will send notice for any settlement
3 under this provision will be sent to the COUNTY; 3) Audit Settlement -DHCS audit. After final
4 reconciliation and settlement, COUNTY and/or DHCS may conduct a review of medical records, cost
5 reports along with support documents submitted to COUNTY in initial submission to determine
6 accuracy and may disallow cost and/or unit of service reported on the CONTRACTOR's legal entity
7 cost report. COUNTY may choose to appeal and therefore reserves the right to defer payback
8 settlement with CONTRACTOR until resolution of the appeal. DHCS Audits will follow federal
9 Medicaid procedures for managing overpayments.
10 If at the end of the Audit Settlement, the COUNTY determines that it overpaid
11 the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related overpayment
12 back to the COUNTY. If at the end of the Audit Settlement process, the COUNTY determines that it
13 underpaid the CONTRACTOR, COUNTY will make a payment for the Medi-Cal related
14 underpayment to the CONTRACTOR based on Federal/State funds received.
15 Funds owed to COUNTY will be due within forty-five (45) days of notification
16 by the COUNTY, or COUNTY shall withhold future payments until all excess funds have been
1 7 recouped by means of an offset against any payments then or thereafter owing to CONTRACTOR
18 under this or any other Agreement.
19 C. Outcome Reports
20 CONTRACTOR shall submit to COUNTY's DSS and/or DBH service outcome
21 reports as requested, at a minimum of every six ( 6) months, as defined in Exhibit A. Outcome reports
22 and outcome requirements are subject to change at COUNTY's DSS or DBH discretion. As of the
23 execution of this Agreement, COUNTY's DSS identified outcome measurements are outlined in
2 4 Exhibit G, "Outcome Measurements," attached hereto and by this reference incorporated herein.
2 5 D. Additional Reports
2 6 CONTRACTOR shall submit to COUNTY's DSS by the 20 th of each month all
2 7 monthly activity and budget reports (requirements are subject to change at the COUNTY s DSS or
2 8 DBH discretion) for the preceding month. COUNTY s DSS Exhibit H, "Monthly Activity Report," is
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1 attached hereto and by this reference incorporated herein.
2 In addition, CONTRACTOR shall also furnish to COUNTY such statements,
3 records, reports, data, and other information as COUNTY may request pertaining to matters covered
4 by this Agreement. In the event that CONTRACTOR fails to provide such reports or other
5 information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly
6 payments until there is compliance. In addition, CONTRACTOR shall provide written notification
7 and explanation to COUNTY within (5) days of any funds received from another source to conduct
8 the same services covered by this Agreement.
9 14. MONITORING
10 CONTRACTOR agrees to extend to COUNTY's staff, COUNTY's DSS Director and
11 DBH Director or their designees, and the California Department of Social Services, the right to review
12 and monitor records, programs or procedures, at any time, in regard to clients, as well as the overall
13 operation ofCONTRACTOR's programs, in order to ensure compliance with the terms and conditions
14 of this Agreement.
15 15. REFERENCES TO LAWS AND RULES
16 In the event any law, regulation, or policy referred to in this Agreement is amended
1 7 during the term thereof, the parties hereto agree to comply with the amended provision as of the
18 effective date of such amendment.
19 16. COMPLIANCE WITH STATE REQUIREMENTS
2 O CONTRACTOR recognizes that COUNTY operates its mental health programs under
21 an agreement with the DHCS, and that under said agreement the State imposes certain requirements on
2 2 COUNTY and its subcontractors. CONTRACTOR shall adhere and be responsible for compliance as
2 3 of the effective date of each Federal, State or local law or regulation specified, including those
2 4 identified in Exhibit I, "Mental Health State Requirements," attached hereto and by this reference
2 5 incorporated herein.
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17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall be required to maintain organizational provider certification by
Fresno County. CONTRACTOR must meet Medi-Cal organization provider standards as listed in
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1 Exhibit J, "Medi-Cal Organizational Provider Standards", attached hereto and by this reference
2 incorporated herein. It is acknowledged that all references to Organizational Provider and/or Provider
3 in Exhibit J shall refer to CONTRACTOR. In addition, CONTRACTOR shall inform every client of
4 their rights under the COUNTY's MHP as set forth in Exhibit K, "Fresno County Mental Health Plan
5 Grievances", attached hereto and by this reference incorporated herein. CONTRACTOR shall also
6 file an "Incident Report" for all incidents involving clients, following the Protocol and using the
7 Worksheet identified in Exhibit I, "Fresno County Mental Health Plan Incident Report", attached
8 hereto and by this reference incorporated herein, or a protocol and worksheet presented by
9 CONTRACTOR that is accepted by COUNTY's DBH Director, or designee.
10 18. CONFIDENTIALITY
11 All services performed by CONTRACTOR under this Agreement shall be in strict
12 conformance with all applicable Federal, State of California and/or local laws and regulations relating
13 to confidentiality.
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19. HEALTH INSURANCE PORTABILITY AND ACCOUNT ABILITY ACT
A. The parties to this Agreement shall be in strict conformance with all applicable
16 Federal and State of California laws and regulations, including but not limited to Sections 5328,
17 10850, and 14100.2 et seq. of the Welfare and Institutions Code (WIC), Sections 2.1 and 431.300 et
18 seq. of Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the California Civil Code
19 and the Health Insurance Portability and Accountability Act (HIPAA), including but not limited to
2 0 Section 1320 D et seq. of Title 42, United States Code (USC) and its implementing regulations,
21 including, but not limited to Title 45, CFR, Sections 142, 160, 162, and 164, and The Health
2 2 Information Technology for Economic and Clinical Health Act (HITECH) regarding the
2 3 confidentiality and security of patient information, and the Genetic Information Nondiscrimination
2 4 Act (GINA) of 2008 regarding the confidentiality of genetic information.
2 5 Except as otherwise provided in this Agreement, CONTRACTOR, as a Business
2 6 Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform functions,
2 7 activities or services for or on behalf of COUNTY, as specified in the Agreement, provided that such
28 use or disclosure shall not violate the HIPAA, USC l320d et seq. The uses and disclosures of PHI
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1 may not be more expansive than those applicable to COUNTY, as the "Covered Entity" under the
2 HIP AA Privacy Rule ( 45 CFR 164.500 et seq.), except as authorized for management, administrative
3 or legal responsibilities of the Business Associate.
4 B. CONTRACTOR, including its subcontractors and employees, shall protect, from
5 unauthorized access, use, or disclosure of names and other identifying information, including genetic
6 information, concerning persons receiving services pursuant to this Agreement, except where
7 permitted in order to carry out data aggregation purposes for health care operations [45 CFR Sections
8 164.504(e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 €(4)(i)]. This pertains to any and all persons
9 receiving services pursuant to a COUNTY funded program. This requirement applies to electronic
10 PHI. CONTRACTOR shall not use such identifying information or genetic information for any
11 purpose other than carrying out CONTRACTOR's obligations under this Agreement.
12 C. CONTRACTOR, including its subcontractors and employees, shall not disclose
13 any such identifying information or genetic information to any person or entity, except as otherwise
14 specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 or other law,
15 required by the Secretary, or authorized by the client/patient in writing. In using or disclosing PHI
16 that is permitted by this Agreement or authorized by law, CONTRACTOR shall make reasonable
1 7 efforts to limit PHI to the minimum necessary to accomplish intended purpose of use, disclosure or
18 request.
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D. For purposes of the above sections, identifying information shall include, but not
be limited to, name, identifying number, symbol, or other identifying particular assigned to the
individual, such as finger or voice print, or a photograph.
E. For purposes of the above sections, genetic information shall include genetic
2 3 tests of family members of an individual, manifestation of disease or disorder of family members of an
2 4 individual, or nay request for or receipt of, genetic services by individual or family members. Family
2 5 member means a dependent or any person who is first, second, third, or fourth degree relative.
26 F. CONTRACTOR shall provide access, at the request of COUNTY, and in the
2 7 time and manner designated by COUNTY, to PHI in a designated record set (as defined in 45 CFR
2 8 Section 164.501 ), to an individual or to COUNTY in order to meet the requirements of 45 CFR
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1 Section 164.524 regarding access by individuals to their PHI. With respect to individual requests,
2 access shall be provided within thirty (30) days from request. Access may be extended if
3 CONTRACTOR cannot provide access and provides individual with the reason for the delay and the
4 date when access may be granted. PHI shall be provided in the form and format requested by the
5 individual or COUNTY.
6 CONTRACTOR shall make any amendment(s) to PHI in a designated record set
7 at the request of COUNTY or individual, and in the time and manner designated by COUNTY in
8 accordance with 45 CPR Section 164.526.
9 CONTRACTOR shall provide to COUNTY or to an individual, in a time and
10 manner designated by COUNTY, information collected in accordance with 45 CFR Section 164.528,
11 to permit COUNTY to respond to a request by the individual for an accounting of disclosures of PHI
12 in accordance with 45 CFR Section 164.528.
13 G. CONTRACTOR shall report to COUNTY, in writing, any knowledge or
14 reasonable belief that there has been unauthorized access, viewing, use, disclosure, security incident,
15 or breach of unsecured PHI not permitted by this Agreement of which it becomes aware, immediately
16 and without reasonable delay and in no case later than two (2) business days of discovery. Immediate
1 7 notification shall be made to COUNTY's Information Security Officer and Privacy Officer, within
18 two (2) business days of discovery. The notification shall include, to the extent possible, the
19 identification of each individual whose unsecured PHI has bee, or is reasonably believed to have been,
2 0 accessed, acquired, used, disclosed, or breached. CONTRACTOR shall take prompt corrective action
21 to cure any deficiencies and any action pertaining to such unauthorized disclosure required by
2 2 applicable Federal and State Laws and regulations. CONTRACTOR shall investigate such breach and
2 3 is responsible for all notifications required by law and regulation or deemed necessary by COUNTY
2 4 and shall provide a written report of the investigation and reporting required to COUNTY's
2 5 Information Security Officer and Privacy Officer. This written investigation and description of any
2 6 reporting necessary shall be postmarked within the thirty (30) working days of the discovery of the
2 7 breach to the addresses below:
2 8 ///
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County of Fresno
Department of Social Services
Privacy Officer
(559) 600-2300
PO BOX 1912
Fresno, CA 93718
County of Fresno
Department of Behavioral Health
HIP AA Representative
(559) 600-9032
444 l E. Kings Canyon
Fresno, CA 93702
County of Fresno
Information Technology Services
Information Security Officer
(559) 600-5800
2048 N. Fine Street
Fresno, CA 93727
County of Fresno
Department of Public Health
Privacy Officer
(559) 600-6405
P.O. Box 11867
Fresno, CA 93775
H. CONTRACTOR shall make its internal practices, books, and records relating to
11 the use and disclosure of PHI received from COUNTY, or created or received by the CONTRACTOR
12 on behalf of COUNTY, in compliance with HIPAA's Privacy Rule, including, but not limited to the
13 requirements set forth in Title 45, CFR, Section 160 and 164. CONTRACTOR shall make its internal
14 practices, books, and records relating to the use and disclosure of PHI received from COUNTY, or
15 created or received by the CONTRACTOR on behalf of COUNTY, available to the United States
16 Department of Health and Human Services (Secretary) upon demand.
1 7 CONTRACTOR shall cooperate with the compliance and investigation reviews
18 conducted by the Secretary. PHI access to the Secretary must be provided during the
19 CONTRACTOR' s normal business hours, however, upon exigent circumstances access at any time
2 0 must be granted. Upon the Secretary's compliance or investigation review, if PHI is unavailable to
21 CONTRACTOR and in possession of a Subcontractor, it must certify efforts to obtain the information
2 2 to the Secretary.
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I. Safeguards
CONTRACTOR shall implement administrative, physical, and technical
safeguards as required by the HIP AA Security Rule, Subpart C of 45 CFR 164, that reasonably and
appropriately protect the confidentiality, integrity, and availability of PHI, including electronic PHI,
that it creates, receives, maintains or transmits on behalf of the COUNTY and to prevent unauthorized
access, viewing, use, disclosure, or breach of PHI other than as provided for by this Agreement.
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1 CONTRACTOR shall conduct an accurate and thorough assessment of the potential risks and
2 vulnerabilities to the confidentiality, integrity and availability of electronic PHI. CONTRACTOR
3 shall develop and maintain a written information privacy and security program that includes
4 administrative, technical and physical safeguards appropriate to the size and complexity of the
5 CONTRACTOR's operations and the nature and scope of its activities. Upon COUNTY request,
6 CONTRACTOR shall provide COUNTY with information concerning such safeguards.
7 CONTRACTOR shall implement strong access controls and other security
8 safeguards and precautions in order to restrict logical and physical access to confidential, personal
9 (e.g., PHI) or sensitive date to authorized users only. Said safeguards and precautions shall include
10 the following administrative and technical password controls for all systems used to process or store
11 confidential, personal, or sensitive data:
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I.
2.
Password must not be:
a.
b.
c.
Shared or written down where they are accessible or recognizable by
anyone else; such as taped to computer screens, stored under keyboards,
or visible in a work area;
A dictionary word; or
Stored in clear text.
Passwords must be:
a.
b.
C.
d.
Eight (8) characters or more in length;
Changed every ninety (90) days;
Change immediately if revealed or compromised; and
Composed of characters from at least three (3) of the following four (4)
groups from the standard keyboard:
1)
2)
3)
4)
Upper case letters (A-Z);
Lowercase Letter (a-z);
Arabic numerals (0 through 9); and
Non-alphanumeric characters (punctuation symbols).
24 -County of Fresno
Fresno, CA
1 CONTRACTOR shall implement the following security controls on each
2 workstation or portable computing device ( e.g., laptop computer) containing confidential, personal, or
3 sensitive data.
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1.
2.
3.
Network-based firewall and/or personal firewall;
Continuously updated anti-virus software; and
Patch management process including installation of all operating
7 system/software vendor security patches.
8 CONTRACTOR will utilize a commercial encryption solution that has received
9 FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable
10 electronic media (including, but not limited to, compact discs and thumb drives) and on portable
11 computing devices (including, but not limited to, laptop and notebook computers).
12 CONTRACTOR will not transmit confidential, persona, or sensitive data via e-
13 mail or other internet transport protocol unless the data is encrypted by a solution that has been
14 validated by the National Institute of Standards and Technology (NIST) as conforming to the
15 Advanced Encryption Standard (AES) Algorithm. CONTRACTOR must apply appropriate sanctions
16 against its employees who fail to comply with these safeguards. CONTRACTOR must adopt
1 7 procedures for terminating access to PHI when employment of employee ends.
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J. Mitigation of Harmful Effect
CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that
is suspected or known to CONTRACTOR of an unauthorized access, viewing, use, disclosure, or
breach of PHI by CONTRACTOR or its subcontractors in violation of the requirements of these
provisions. CONTRACTOR must document suspected or known harmful effects and the outcome.
K. CONTRACTOR's Subcontractors
2 4 CONTRACTOR shall ensure that any contractors, including subcontractors, if
2 5 applicable, to whom CONTRACTOR provides PHI received from or created or received by
2 6 CONTRACTOR on behalf of COUNTY, agree to the same restriction, safeguards, and conditions that
2 7 apply to CONTRACTOR with respect to such PHI and to incorporate, when applicable, the relevant
2 8 provisions of these provisions into each subcontract or sub-award to such agents of subcontractors.
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L. Employee Training and Discipline
CONTRACTOR shall train and use reasonable measure to ensure compliance
with the requirements of these provisions by employees who assist in the performance of functions or
activities on behalf of COUNTY under this Agreement and use or disclose PHI and discipline such
employees who intentionally violate any provisions of these provisions, including termination of
employment.
M. Termination for Cause
Upon COUNTY's knowledge of a material breach of these provisions by
CONTRACTOR, COUNTY shall either:
1. Provide an opportunity for CONTRACTOR to cure the breach or end the
violation and terminate this Agreement if CONTRACTOR does not cure the breach or end the
violations within the time specified by COUNTY; or
2. Immediately terminate this Agreement if CONTRACTOR has breached a
material term of these provisions and cure is not possible.
3. If neither cure nor termination is feasible, the COUNTY Privacy Officer
shall reports the violation to the Secretary of the U.S. Department of Health and Human Services.
N. Judicial or Administrative Proceedings
COUNTY may terminated this Agreement in accordance with the terms and
conditions of this Agreement as written hereinabove, if: (1) CONTRACTOR is found guilty in a
criminal proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act; or (2)
a finding or stipulation that the CONTRACTOR has violated a privacy or security standard or
requirement of the HITECH Act, HIPAA or other security or privacy laws in an administrative or civil
proceeding in which the CONTRACTOR is a party.
0. Effect of Termination
Upon termination or expiration of this Agreement for any reason,
CONTRACTOR will deliver copies of all client records to COUNTY within (15) working days from
the date of expiration or termination. Client records include all medical/clinical records, monitoring
records, all data entered into the COUNTY's billing system and all fiscal records related to funding
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1 received under this agreement. For other related records CONTRACTOR shall return or destroy all
2 PHI received from COUNTY (or created or received by CONTRACTOR on behalf of COUNTY) that
3 CONTRACTOR still maintains in any form, and shall retain no copies of such PHI. If return or
4 destruction of PHI is not feasible, it shall continue to extend the protections of these provisions to such
5 information, and limit further use of such PHI to those purposes that make the return or destruction of
6 such PHI infeasible. The provision shall apply to PHI that is in the possession of subcontractors or
7 agents, if applicable, of CONTRACTOR. If CONTRACTOR destroys the PHI data, a certification of
8 date and time of destruction shall be provided to the COUNTY by CONTRACTOR.
9 P. Disclaimer
10 COUNTY makes no warranty or representation that compliance by
11 CONTRACTOR with these provisions, the HITECH Act, HIP AA or the HIP AA regulations will be
12 adequate or satisfactory for CONTRACTOR's own purpose or that any information in
13 CONTRACTOR's possession or control, or transmitted or received by CONTRACTOR, is or will be
14 secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR is solely
15 responsible for all decisions made by CONTRACTOR regarding the safeguarding of PHI.
16 Q. Amendment
1 7 The parties acknowledge that Federal and State laws relating to electronic data
18 security and privacy are rapidly evolving and that amendment of these provisions may be required to
19 provide for procedures to ensure compliance with such developments. The parties specifically agree to
2 O take such action as is necessary to amend this Agreement in order to implement the standards and
21 requirements of HIP AA, the HIP AA regulations, the HITECH Act and other applicable laws relating
2 2 to the security or privacy that CONTRACTOR does not enter into an amendment providing
2 3 assurances regarding the safeguarding of PHI that COUNTY in its sole discretion, deems sufficient to
2 4 satisfy the standards and requirements of HIP AA, the HIPAA regulations and the HITECH Act.
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R. No Third-Party Beneficiaries
Nothing express or implied in the terms and conditions of these provisions is
intended to confer, nor shall anything herein confer, upon any person other than COUNTY or
27 County of Fresno
Fresno, CA
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CONTRACTOR and their respective successors or assignees, any rights, remedies, obligations or
liabilities whatsoever.
s. Interpretation
4 The terms and conditions in these provisions shall be interpreted as broadly as
5 necessary to implement and comply with HIPAA, the HIPAA regulations and applicable State laws.
6 The parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved
7 in favor of a meaning that complies and is consistent with HIP AA and the HIP AA regulations.
8 T. Regulatory References
9 A reference in the terms and conditions of these provisions to a section in the
10 HIP AA regulations means the section as in effect of as amended.
u. Survival 11
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The respective rights and obligations of CONTRACTOR as stated in this Section
19 shall survive the termination or expiration of this Agreement.
V. No Waiver of Obligations
15 No change, waiver or discharge of any liability or obligation hereunder on any
16 one or more occasions shall be deemed a waiver of performance of any continuing or other obligation,
1 7 or shall prohibit enforcement of any obligation on any other occasion.
18 20. DATA SECURITY
19 For the purpose of preventing the potential loss, misappropriation or inadvertent access,
2 0 viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
21 of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
2 2 enter into a contractual relationship with the COUNTY for the purpose of providing services under
2 3 this Agreement must employ adequate data security measures to protect the confidential information
2 4 provided to CONTRACTOR by the COUNTY, incJuding but not limited to the following:
25 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
2 6 CONTRACTOR may not connect to COUNTY networks via personally-owned
2 7 mobile, wireless or handheld devices, unless the following conditions are met;
28 Ill
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I.
2.
3.
4.
CONTRACTOR has received authorization by COUNTY for
telecommuting purposes;
Current virus protection software is in place;
Mobile device has the remote wipe feature enabled; and
A secure connection is used.
CONTRACTOR-Owned Computers or Computer Peripherals
7 CONTRACTOR may not bring CONTRACTOR-owned computers or computer
8 peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief
9 Information Officer, or designee, including but not limited to mobile storage devices. If data is
10 approved to be transferred, data must be stored on a secure server approved by COUNTY and
11 transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
12 connection. Said data must be encrypted.
13 C. COUNTY-Owned Computer Equipment
14 CONTRACTOR, including its subcontractors and employees, may not use
15 COUNTY computers of computer peripherals on non-COUNTY premises without prior authorization
16 from the COUNTY's Chief Information Officer, or designee.
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D. CONTRACTOR may not store COUNTY's private, confidential or sensitive
data on any hard-disk drive, portable storage devise, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the
2 O integrity and security of COUNTY's confidential information and to prevent unauthorized access,
21 viewing, use or disclosure of data maintained in computer files, program documentation, data
2 2 processing systems, data files and data processing equipment which stores or processes COUNTY
2 3 data internally and externally.
24 F. Confidential client information transmitted to one party by the other by means of
2 5 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
2 6 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
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G. CONTRACTOR is responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY's confidential information,
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data maintained in computer files, program documentation, data processing systems, data files and
data processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR's responses to all
4 incidents arising from a possible breach of security related to COUNTY's confidential client
5 information provided to CONTRACTOR. CONTRACTOR will be responsible to issue any
6 notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole
7 discretion. CONTRACTOR will be responsible for all costs incurred as a result of providing the
8 required notification.
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21. PROPERTY OF COUNTY
A. COUNTY and CONTRACTOR recognizes that fixed assets are tangible and
intangible property obtained or controlled under COUNTY's MHP for use in operational capacity and
will benefit COUNTY for a period more than one (1) year. Depreciation of the qualified items will
be on a straight-line basis.
Ill
For COUNTY purposes, fixed assets must fulfill three (3) qualifications:
1.
2.
3.
Asset must have life span of over one (1) year.
The asset is not a repair part.
The asset must be valued at or greater than the capitalization thresholds
for the asset type:
Asset type
• land
• buildings and improvements
• infrastructure
• be tangible
0 equipment
0 vehicles
• or intangible asset
0 Internally generated software
0 Purchased software
0 Easements
0 Patents
• and capital lease
-30 -
Threshold
$0
$100,000
$100,000
$5,000
$100,000
$5,000
County of Fresno
Fresno, CA
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Qualified fixed asset equipment is to be reported and approved by COUNTY. If
it is approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed
asset log will be maintained by COUNTY's Asset Management System and annual inventoried until
the asset is fully depreciated. During the terms of this Agreement, CONTRACTOR's fixed assets
may be inventoried in comparison to COUNTY's DSS Asset Inventory System.
B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than One Thousand and No/I 00 Dollars ($1,000.00), with over one (I) year life span, and are
mobile and high risk of theft or loss are sensitive assets. Such sensitive items are not limited to
computers, copiers, televisions, cameras and other sensitive items as determined by COUNTY's DSS
Director, or designee. CONTRACTOR maintains a tracking system on the items and are not required
to be capitalize or depreciated. The items are subject to annual inventory for compliance.
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate
in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration
of this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
COUNTY-owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
unable to produce the assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
l. To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2. To label all items of equipment with COUNTY assigned program number, to
perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used, in accordance with procedures developed by COUNTY.
All such lists shall be submitted to COUNTY within ten ( 10) days of any request therefore; and
3. To report in writing to COUNTY immediately after discovery, the lost or
theft of any items of equipment. For stolen items, the local law enforcement agency must be
contacted and a copy of the police report submitted to COUNTY.
31 -County of Fresno
Fresno, CA
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D. The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY's DBH, shall fulfill the provisions of
this Agreement as appropriate, and must be directly related to CONTRACTOR's services or activity
under the terms of this Agreement. COUNTY's DSS may refuse reimbursement for any costs
resulting from equipment purchased, which are incurred by CONTRACTOR, if prior written
approval has not been obtained from COUNTY.
E. CONTRACTOR must obtain prior written approval from COUNTY's DBH
whenever there is any modification or change in the use of any property acquired or improved, in
whole or in part, using funds under this agreement. If any real or personal property acquired or
improved with said funds identified herein is sold and/or is utilized by CONTRACTOR for a use
which does not qualify under this program, CONTRACTOR shall reimburse COUNTY in an amount
equal to the current fair market value of the property, less any portion thereof attributable to
expenditures of non-program funds. These requirements shall continue in effect for the life of the
property. In the event the program is closed out, the requirements for this Section 21 shall remain in
effect for activities or property funded with said funds, unless action is taken by the State government
to relieve COUNTY of these obligations.
22. NON-DISCRIMINATION
18 During the performance of this Agreement, CONTRACTOR shall not unlawfully
19 discriminate against any employee or applicant for employment, or recipient of services, because of
2 0 race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age
21 or sex, pursuant to all applicable State and Federal statutes and regulations.
22 23. CONFLICT OF INTEREST
2 3 No officer, agent, or employee of COUNTY who exercises any function or
2 4 responsibility for planning and carrying out the services provided under this Agreement shall have any
2 5 direct or indirect personal financial interest in this Agreement. No officer, agent, or employee of
2 6 COUNTY who exercises any function or responsibility for planning and carrying out the services
2 7 provided under this Agreement shall have any direct or indirect personal financial interest in this
28 Agreement. In addition, no employee of COUNTY shall be employed by CONTRACTOR to fulfill
-32 -County of Fresno
Fresno, CA
1 any contractual obligations with COUNTY. CONTRACTOR shall also comply with all Federal, State
2 of California, and local conflict of interest laws, statutes, and regulations, which shall be applicable to
3 all parties and beneficiaries under this Agreement and any officer, agent, or employee of COUNTY.
4 24. CHARITABLE CHOICE
5 CONTRACTOR may not discriminate in its program delivery against a client or
6 potential client on the basis ofreligion or religious belief, a refusal to hold a religious belief, or a
7 refusal to actively participate in a religious practice. Any specifically religious activity or service
8 made available to individuals by CONTRACTOR must be voluntary as we as separate in time and
9 locations from COUNTY-funded activities and services. CONTRACTOR shall inform COUNTY as
10 to whether it is faith-based. If CONTRACTOR identifies as faith-based it must submit to COUNTY's
11 DSS a copy of its policy on referring individuals to an alternate treatment provider, and include a copy
12 of this policy in its client admission forms. The policy must inform individuals that they may be
13 referred to an alternative provider if the object the religious nature of the program, and include a
14 notice to COUNTY's DSS. Adherence to this will be monitored during annual site reviews, and a
15 review of client files. If CONTRACTOR identifies as faith-based, by July 1st of each year
16 CONTRACTOR will be required to report to COUNTY's DSS the number of individual who
1 7 requested referrals to alternate providers based on religious objection.
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25. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A. Title 6 of the Civil Rights Act of 1964 ( 42 USC Section 2000d, and 45 CFR Part
80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal
access and participation in federally funded programs through the provision of comprehensive and
quality bilingual services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients, including, but not limited to,
assessing the cultural and linguistic needs of its clients, training of staff on the policies and
-33 -County of Fresno
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procedures, and monitoring its language assistance program. The CONTRACTOR's procedures must
include ensuring compliance of any sub-contracted providers with these requirements.
C.
D.
CONTRACTOR shall not use minors as interpreters.
CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR's services who have limited or no English language
proficiency, including services to persons who are deaf or blind. Interpreter and translation services
shall be provided as necessary to allow such participants meaningful access to the programs, services
and benefits provided by CONTRACTOR. Interpreter and translation services, including translation
of CONTRACTOR's "vital documents" (those documents that contain information that is critical for
accessing CONTRACTOR's services or are required by law) shall be provided to participants at no
cost to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or
partners who interpret or translate for a program participant, or who directly communicate with a
program participant in a language other than English, demonstrate proficiency in the participant's
language and can effectively communicate any specialized terms and concepts peculiar to
CONTRACTOR's services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within sixty (60) days from date of contract execution, CONTRACTOR's
plan to address all fifteen national cultural competency standards as set forth in the "National
Standards on Culturally and Linguistically Appropriate Services (CLAS)"
http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. COUNTY's annual on-site review
of CONTRACTOR shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR's plan must be
updated accordingly.
26. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowances of reimbursement under Section
1861(v)(l)(I) of the Social Security Act, (42 USC§ 1395x, subd. (v)(l)[I]), until the expiration of four
(4) years after the furnishing of services under this Agreement, CONTRACTOR shall make available,
-34 -County of Fresno
Fresno, CA
1 upon written request of the Secretary of the United States Department of Health and Human Services,
2 or upon request of the Comptroller General of the United States General Accounting Office, or any of
3 their duly authorized representatives, a copy of this Agreement and such books, documents, and
4 records as are necessary to certify the nature and extent of the costs of these services provided by
5 CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event
6 CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value
7 or cost of Ten Thousand and No/I 00 Dollars ($10,000.00) or more over a twelve (12) month period,
8 with a related organization, such Agreement shall contain a clause to the effect that until the expiration
9 of four ( 4) years after the furnishing of such services pursuant to such subcontract, the related
10 organizations shall make available, upon written request of the Secretary of the United States
11 Department of Health and Human Services, or upon request of the Comptroller General of the United
12 States General Accounting Office, or any of their duly authorized representatives, a copy of such
13 subcontract and such books, documents, and records of such organization as are necessary to verify
14 the nature and extent of such costs.
27. SINGLE AUDIT CLAUSE 15
16 A. If CONTRACTOR expends Five Hundred Thousand and No/I 00 Dollars
1 7 ($500,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to
18 conduct an annual audit in accordance with the requirements of the Single Audit requirements as set
19 forth in the Office of Management and Budget Uniform Administrative Requirements, Costs
2 0 Principles, and Audit Requirements for Federal Awards, Subpart F, Section 200.501 (b ).
21 CONTRACTOR shall submit said audit and management letter to COUNTY. The audit must include
2 2 a statement of findings or a statement that there were no findings. If there were negative findings,
2 3 CONTRACTOR must include a corrective action plan signed by an authorized individual.
2 4 CONTRACTOR agrees to take action to correct any material non-compliance or weakness found as a
2 5 result of such audit. Such audit shall be delivered to COUNTY's DSS and/or DBH Business Office
2 6 for review within nine (9) months of the end of any fiscal year in which funds were expended and/or
2 7 received for the program. Failure to perform the requisite audit functions as required by this
2 8 Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY' s option,
35 -County of Fresno
Fresno, CA
1 contracting with a public accountant to perform said audit, or, may result in the inability of COUNTY
2 to enter into future agreements with CONTRACTOR. All audit costs related to this Agreement are the
3 sole responsibility of CONTRACTOR.
4 B. A single audit report is not applicable if CONTRACTOR's Federal contracts do
5 not exceed the Five Hundred Thousand and No/l00 Dollars ($500,000.00) requirement or
6 CONTRACTOR's only funding is through drug-related Medi-Cal. If a single audit is not applicable, a
7 program audit must be performed and a program audit report with management letter shall be
8 submitted by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR's
9 solvency. Said audit report shall be delivered to COUNTY's DSS and/or DBH for review, no later
10 than nine (9) months after the close of the fiscal year in which the funds supplied through this
11 Agreement are expended. Failure to comply with this Act may result in COUNTY performing the
12 necessary audit tasks or contracting with a qualified accountant to perform said audit. All audit costs
13 related to this Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective
14 action to eliminate any material noncompliance or weakness found as a result of such audit. Audit
15 work performed by COUNTY under this Section 27 shall be billed to the CONTRACTOR at
16 COUNTY's cost, as determined by COUNTY's Auditor-Controller/Treasurer-Tax Collector.
17 C. CONTRACTOR shall make available all records and accounts for inspection by
18 COUNTY, the State of California, if applicable, the Comptroller General of the United States, the
19 Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
2 0 Period of at least three (3) years following final payment under this Agreement or the closure of all
21 other pending matters, whichever is later.
22 28. COMPLIANCE
2 3 CONTRACTOR shall comply with COUNTY's "Fresno County Mental Health
2 4 Compliance -Contractor Code of Conduct and Ethics", as identified in Exhibit E. Within thirty (30)
2 5 days of entering into the Agreement with the COUNTY, CONTRACTOR shall have all of its
2 6 employees, agents and subcontractors providing services under this Agreement certify in writing, that
2 7 he or she has received, read, understood, and shall abide by the "Contractor Code of Conduct and
2 8 Ethics". CONTRACTOR shall additionally ensure that within thirty (30) days of hire, all new
36 -County of Fresno
Fresno, CA
1 employees, agents and subcontractors providing services under this Agreement certify in writing that
2 he or she has received, read, understood, and shall abide by the "Contractor Code of Conduct and
3 Ethics". CONTRACTOR understands that the promotion of and adherence to the Code of Conduct is
4 an element in evaluating the performance of CONTRACTOR and its employees, agents and
5 subcontractors.
6 Within thirty (30) days of entering into this Agreement, and annually thereafter, all
7 employees, agents and subcontractors providing services under this Agreement shall complete general
8 compliance training and appropriate employees, agents and subcontractors shall complete
9 documentation and billing or billing/reimbursement training. All new employees, agents and
10 subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual
11 who is required to attend training shall certify in writing that he or she has received the required
12 training. The certification shall specify the type of training received and the date received. The
13 certification shall be provided to the COUNTY's Compliance Officer at 3133 N. Millbrook, Fresno,
14 CA 93703. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed
15 upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of the terms of
16 this Agreement.
17 29. ASSURANCES
18 In entering into this Agreement, CONTRACTOR certifies that it nor any of its officers
19 are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
2 0 Health Care Programs: that it has not been convicted of a criminal offense related to the provision of
21 health care items or services; nor has it been reinstated to participation in the Federal Health Care
2 2 Programs after a period of exclusion, suspension, debarment, or ineligibility. If COUNTY learns,
2 3 subsequent to entering into this Agreement, that CONTRACTOR is ineligible on these grounds,
2 4 COUNTY will remove CONTRACTOR from responsibility for, or involvement with, COUNTY' s
2 5 business operations related to the Federal Health Care Programs and shall remove such
2 6 CONTRACTOR from any position in which CONTRACTOR's compensation, or the items or services
2 7 rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or
2 8 indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until such time as
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Fresno, CA
1 CONTRACTOR is reinstated into participation in the Federal Health Care Programs.
2 A. If COUNTY has notice that CONTRACTOR has been charged with a criminal
3 offense related to any Federal Health Care Program, or is proposed for exclusion during the term of
4 this Agreement, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the
5 accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
6 circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution
7 of the charges or the proposed exclusion.
8 B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
9 subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
1 0 under this Agreement, will be queried as to whether ( 1) they are now or ever have been excluded,
11 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
12 they have been convicted of a criminal offense related to the provision of health care items or services;
13 and/or (3) they have been reinstated to participation in the Federal Health Care Programs after a period
14 of exclusion, suspension, debarment, or ineligibility.
15 1. In the event the potential employee or subcontractor informs
16 CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
1 7 convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
18 hires or engages such potential employee or subcontractor, CONTRACTOR will ensure that said
19 employee or subcontractor does no work, either directly or indirectly relating to services provided to
20 COUNTY.
21 2. Notwithstanding the above, COUNTY at its discretion may terminate this
22 Agreement in accordance with Section 3 of this Agreement, or require adequate assurance (as defined
2 3 by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
2 4 CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
2 5 COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be
2 6 determined by COUNTY to protect the interests of COUNTY clients.
27 C. CONTRACTOR shall verify (by asking the applicable employees and
2 8 subcontractors) that all current employees and existing subcontractors who, in each case, are expected
-38 -County of Fresno
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1 to perform professional services under this Agreement: ( 1) are not currently excluded, suspended,
2 debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
3 convicted of a criminal offense related to the provision of health care items or services; and (3) have
4 not been reinstated to participation in the Federal Health Care Program after a period of exclusion,
5 suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
6 CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to participate
7 in the Federal Health Care Programs, or has been convicted of a criminal offense relating to the
8 provision of health care services, CONTRACTOR will ensure that said employee or subcontractor
9 does no work, either direct or indirect, relating to services provided to COUNTY.
10 1. CONTRACTOR agrees to notify COUNTY immediately during the term
11 of this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each
12 case, is providing professional services under this Agreement is excluded, suspended, debarred or
13 otherwise ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal
14 offense relating to the provision of health care services.
15 2. Notwithstanding the above, COUNTY at its discretion may terminate this
16 Agreement in accordance with the Termination Section 3 of this Agreement, or require adequate
17 assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
18 subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to services
19 provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to
2 0 be determined by COUNTY to protect the interests of COUNTY clients.
21 D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
2 2 information from COUNTY which may be necessary to complete any internal or external audits
2 3 relating to CONTRACTOR's compliance with the provisions of this Section 29.
24 E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
25 imposed upon COUNTY by the Federal Government as a result ofCONTRACTOR's violation of
2 6 CONTRACTOR's obligations as described in this Section 29.
27 Ill
28 Ill
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Fresno, CA
1 30. AUDITS AND INSPECTIONS
2 CONTRACTOR shall at any time during business hours, and as often as the COUNTY
3 may deem necessary, make available to the COUNTY for examination all ofits records and data with
4 respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the
5 COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to ensure
6 CONTRACTOR's compliance with the terms of this Agreement.
7 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
8 CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a
9 period of three (3) years after final payment under contract (Government Code Section 8546.7).
10 31. PROHIBITION ON PUBLICITY
11 None of the funds, materials, property or services provided directly or indirectly under
12 this Agreement shall be used for CONTRACTOR's advertising, fundraising, or publicity (i.e.,
13 purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
14 Notwithstanding the above, publicity of the services described in Section l of this Agreement shall be
15 allowed as necessary to raise public awareness about the availability of such specific services when
16 approved in advance by COUNTY's DSS Director, or designee, and at a cost to be provided identified
1 7 in Exhibit B for such items as written/printed materials, the use of media (i.e., radio, television,
18 newspapers) and any other related expense(s).
19 32. COMPLAINTS
2 0 CONTRACTOR shall log complaints and the disposition of all complaints from a client
21 or client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries
22 concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th) day of
2 3 the following month, in a format that is mutually agreed upon. In addition to the detailed complaint
2 4 log, CONTRACTOR shall provide details and attach documentation of each complaint with the log.
25 CONTRACTOR shall post signs informing consumer of their right to file a complaint or grievance.
2 6 CONTRACTOR shall notify COUNTY of all incidents reportable to state licensing bodies that affect
2 7 COUNTY consumers within twenty-four (24) hours of receipt of a complaint.
2 8 ///
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1 Within ten (10) days after each incident or complaint affecting COUNTY-sponsored clients,
2 CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative
3 details of the complaint, the complaint and CONTRACTOR's disposition of, or corrective action taken
4 to resolve the complaint.
5 33. NOTICES
6 The persons having authority to give and receive notices under this Agreement and their
7 addresses include the following:
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COUNTY
Director, Fresno County
Department of Social Services
PO BOX 1912
Fresno, CA 93718
CONTRACTOR
Chief Executive Officer
Familiesfirst, Inc., dba EMQ FamiliesFirst
25 l Llewellyn Ave
Campbell, CA 95008
12 Any and all notices between COUNTY and CONTRACTOR provided for or permitted
13 under this Agreement or by law shall be in writing and shall be deemed duly served when personally
14 delivered to one of the parties, or in lieu of such personal service, when deposited in the United States
15 Mail, postage prepaid, addressed to such party.
16 34. DISCLOSURE -CRIMINAL HISTORY & CIVIL ACTIONS
1 7 CONTRACTOR is required to disclose if any of the following conditions apply to them,
18 their owners, officers, corporate managers and partners (hereinafter collectively referred to as
19 "CONTRACTOR"):
20 A. Within the three-year period preceding this Agreement award, they have been
21 convicted of, or had a civil judgment rendered against them for:
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2.
3.
4.
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 a federal or state antitrust statute;
Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
False statements or receipt of stolen property.
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Fresno, CA
1 B. Within the three-year period preceding the Agreement award, they have had a
2 public transaction (federal, state, or local) terminated for cause or default.
3 Disclosure of the above information will not automatically eliminate
4 CONTRACTOR from further business consideration. The information will be considered as part of
5 the determination of whether to continue and/or renew this Agreement and any additional information
6 or explanation that a CONTRACTOR elects to submit with the disclosed information will be
7 considered. If it is later determined that the CONTRACTOR failed to disclose required information,
8 any Agreement awarded to such CONTRACTOR may be immediately voided and terminated for
9 material failure to comply with the terms and conditions of the award.
10 CONTRACTOR must sign Exhibit M, "Certification Regarding Debarment,
11 Suspension, and Other Responsibility Matters-Primary Covered Transactions," attached hereto and by
12 this reference incorporated herein. Additionally, CONTRACTOR must immediately advise the
13 COUNTY in writing if, during the term of the Agreement: (I) CONTRACTOR becomes suspended,
14 debarred, excluded or ineligible for participation in federal or state funded programs or from receiving
15 federal funds as listed in the excluded parties list system (http://www/sam/gov): or (2) any of the
16 above listed conditions become applicable to CONTRACTOR. CONTRACTOR shall indemnify,
1 7 defend and hold the COUNTY harmless for any loss or damage resulting from a conviction,
18 debarment, exclusion, ineligibility or other matter listed in the signed Certification Regarding
19 Debarment, Suspension, and Other Responsibility Matters.
20 35. DISCLOSURE OF SELF-DEALING TRANSACTIONS
21 This provision is only applicable if the CONTRACTOR is operating as a corporation (a
2 2 for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
2 3 changes its status to operate as a corporation.
2 4 Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing
2 5 transactions that they are a party to while CONTRACTOR is providing goods or performing services
2 6 under this Agreement. A self-dealing transaction shall mean a transaction to which the
2 7 CONTRACTOR is a party and in which one or more of its directors has a material financial interest.
28 Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
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1 by completing and signing Exhibit N, "Self-Dealing Transaction Disclosure Form", attached hereto
2 and by this reference incorporated herein. The "Self-Dealing Transaction Disclosure Form" shall be
3 submitted to the COUNTY prior to commencing with the self-dealing transaction or immediately
4 thereafter.
5 36. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
6 INFORMATION
7 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent,
8 or managed care entity as defined in Code of Federal Regulations (C.F .R}, Title 42 § 455. IO I,
9 455.104, and 455.106(a)(l ),(2).
10 In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.l06(a)(l),(2),
11 the following information must be disclosed by CONTRACTOR by completing Exhibit 0,
12 "Disclosure of Ownership and Control Interest Statement", attached hereto and by this reference
13 incorporated herein. CONTRACTOR shall submit this form to the COUNTY's DBH within thirty
14 (30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any
15 changes to this information within thirty five (35) days of occurrence by completing Exhibit 0.
16 Submissions shall be scanned pdf copies and are to be sent via email to
1 7 DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
18 37. GOVERNING LAW
19 The parties agree that for the purpose of venue, performance under this Agreement is in
2 0 Fresno County, California.
21 The rights and obligations of the parties and all interpretation and performance of this
2 2 Agreement shall be governed in all respects by the laws of the State of California.
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38. ENTIRE AGREEMENT
This Agreement, including all Exhibits, COUNTY's Revised RFP No. 952-5322 and
CONTRACTOR's Response thereto constitutes the entire Agreement between CONTRACTOR and
COUNTY with respect to the subject matter hereof and supersedes all previous agreement
negotiations, proposals, commitments, writings, advertisements, publications, and understandings of
any nature whatsoever unless expressly included in this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
year first hereinabove written.
CONTRACTOR:
FAMILIESFIRST, INC.,
dba EMQ F~LIESFIRST
,, I. ; . /
By // _dl-9 _ _,,,,t~ J--
Print Name: c~ l;< ') {µ ~ ( :\~
Title: CU · 't.-l Cl ;· .,-\ l4-l 0··U. Y~k..
Chairman of the Board, or
President, or any Vice President
! __,--
Print Name: Ja.s cJ1 ~---------
Title:
( > r o
Secretary ( of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Date: vy:/4_;i_ J; _r---+-=--'-77'--'----
Mailing Address:
251 Llewellyn A venue
Campbell, CA 95008
Phone No.: (408) 379-3790
Fax No.: (408) 364-4013
Contact: Chief Financial Officer
COUNTY OF FRESNO
By-=::c.....'-¥-''--=--='-=--------'--
Deborah A. Poochigian, Chai
Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-44 -County of Fresno
Fresno, CA
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APPROVED AS TO LEGAL FORM:
DANIEL C. CEDERBORG, COUNTY COUNSEL
VEDAS TO ACCOUNTING F.
VIC CROW, C.P.A., AUDITOR-C
TREASURER-TAX COLLECTOR
By ~{44"'
REVIEWED AND RECOMMENDED FOR APPROVAL:
eira, 1rector
Department of Social Services
REVIEWED AND RECOMMENDED FOR APPROVAL:
~~ By_-----'------'--------
Dawan Utecht, Director
Department of Behavioral Health
Fund/Subclass:
Organization:
Account/Program:
0001/10000
56107663 i ,i7 O .it I, ll-r,coo
5(,102666-'i'Ct>m 7'6t-J/7 lJ1 1 3; 3·1~oou
7223/~
26 FY 2015-16
FY 2016-17
Max. Non-Medi-Cal & Other Services
$1,125,000
$1,125,000
27 FY 2017-18 $1,125,000
28
-45 -
Max. Total Compensation
$4,500,000
$4,500,000
$4,500,000
County of Fresno
Fresno, CA
SUMMARY OF SERVICES
ORGANIZATION: FamiliesFirst, Inc., dba EMO FamiliesFirst
Exhibit A
Page 1 of 6
SERVICES: Senate Bill 163 Wraparound and Therapeutic Foster Care Services
CONTRACT PERIOD: July 1, 2015 -June 30, 2018
AMOUNT: $4,500,000 (July 1, 2015-June 30, 2016)
$4,500,000 (July 1, 2016-June 30, 2017)
$4,500,000 (July 1, 2017 -June 30, 2018)
SUMMARY OF SERVICES: CONTRACTOR shall perform all Wraparound Approach Services
(Wraparound), including emergency mental health support services, and Therapeutic Foster
Care (TFC) services and fulfill all responsibilities identified in COUNTY's Request for Proposal
(RFP) No. 952-5322 dated January 5, 2015, the RFP Addendum dated January 22, 2015
(referred to as the Revised RFP), and CONTRACTOR's response to said Revised RFP dated
February 11, 2015 and all incorporated herein by reference and made part of this Agreement.
Services provided, at a slot capacity of 150 children at any given time, include specialty mental
health services, Wraparound Approach Services (Wraparound) and TFC, that emphasize the
strength of the child and the family. Services are highly coordinated, highly individualized and
unconditional, they address needs and achieve positive outcomes in the lives of enrolled
children and their families and may include, but are not limited to: mentoring, tutoring,
recreational activities, shadowing, community involvement, school-sponsored activities, faith-
based programs and activities, and volunteerism.
CONTRACTOR recognizes that the COUNTY operates its mental health programs under an
agreement with the State Department of Health Care Services (DHCS), and that under said
agreement the State imposes certain requirements on COUNTY and its subcontractors.
CONTRACTOR shall adhere and be responsible for compliance as of the effective date of each
Federal, State or local law or regulation specified. In the event any, regulation or policy referred
to in the Agreement, RFP or this Exhibit A is amended during the term of this Agreement, the
parties agree to comply with the amended provision as of the effective date of such amendment.
SCHEDULE OF SERVICES: CONTRACTOR office(s) shall be open Monday through Friday, 8
a.m. to 5 p.m. Staff can access the office outside of these hours should they need to provide
services on site after 5 p.m. or on weekends. The majority of services will be provided in the
community and are scheduled on days and times that are convenient to the families, including
evenings and weekends. Youth/families also have access to stand by a crisis support phone
line twenty-four (24) hours/day, seven (7) days/week. The stand-by worker, in consultation with
a supervisor, will determine the level of support needed to address the crisis, which ranges from
telephone support and coaching to immediate in person response by staff.
TARGET POPULATION: 1) An enrolled child who has been adjudicated as either a dependent
or ward of the juvenile court pursuant to the Welfare Institution Code, Section 300, 601, or 602
and who would be placed in a group home licensed by COUNTY's Department of Social
Services (DSS) at a rate classification level (RCL) of 1 O or higher; 2) A child/youth who has
been adjudicated as either a dependent or ward and who has experienced three (3) or more
placement moves or psychiatric hospitalizations within the past twenty-four (24) months; 3) A
child/youth who is in an adoptive placement or has a finalized adoption who qualifies for
Exhibit A
Page 2 of 6
Adoption Assistance Program (MP) benefits and has an urgent and/or intensive mental health
need which causes impairment at school, home, and/or in the community; 4) A child/youth who
is at imminent risk of placement in a RCL 10 or above, or currently placed in a RCL 1 O or above
and is within sixty (60) days of returning to the community.
CONTRACTOR AGREES to provide all Wraparound, emergency medical supports and TFC
services identified in COUNTY's Revised RFP. The following are highlights and/or further
defined/updated responsibilities of said items.
CONTRACTOR SHALL:
1. Work collaboratively in an integrated service delivery model within the community,
region and state to obtain the outcomes, goals and strategies of the California
Partners for Permanency (CAPP) and Katie A. Core Practice Models, SB163 Service
Models and Therapeutic Foster Care Models.
2. Have the ability to comply with applicable Federal and State of California laws and
regulations, including but not limited to the Business Associate requirements of the
Health Insurance Portability and Accountability Act (HIPM). (45 CFR parts 160, 162
and 164); the Health Information Technology for Economic and Clinical Health Act
regarding the confidentiality and security of patient information; and the Genetic
Information Nondiscrimination Act (GINA) of 2008 regarding the confidentiality of
genetic information.
3. Maintain responsibility to provide and appropriately bill for Katie A. Subclass members
if medically necessary and provided within the CAPP and Katie A. Core Practice
Model and in accordance with the "Medi-Cal Manual for Intensive Care Coordination
(ICC), Intensive Home Based Services (IHBS) & Therapeutic Foster Care (TFC) for
Katie A. Subclass Members", incorporated herein by reference.
4. Hire racially and ethnically diverse staff, whenever possible, reflective of the target
population to provide or assist with culturally competent, client and family-driven
mental health and supportive services.
5. Recruit qualified subcontractors, as needed, to provide authorized Wraparound
services.
6. Work cooperatively and collaboratively with Child Welfare Service (CWS) staff, Child
Welfare Mental Health Program staff and all treatment providers, caregivers, Foster
Family Agencies (FFA) to achieve the individual and collective treatment goals and
support the CWS case plan, communicate/resolve barriers to care, provide
continuity and warm-handoffs whenever possible when clients transition from
higher-to-lower or lower-to-higher levels of care whether within or outside of Fresno
County.
7. Ensure clinical supervision of registered/waivered mental health clinicians, including
co-signing or reviewing documentation and claiming in Electronic Medical Records as
required by the Board of Behavioral Sciences (BBS) or COUNTY requirements. All
supervision shall be provided by licensed Clinical Supervisors. The Clinical
Supervisor shall be two (2) years post-licensure and have completed the required
training in accordance with the BBS.
8. Arrange for and complete a mental health assessment, if needed, including clinical
analysis of the history and current status of a beneficiary's mental, emotional, or
behavioral disorder; relevant cultural issues and history; diagnosis; and use of testing
procedures.
Exhibit A
Page 3 of 6
9. Address the demographic make-up and population trends of the Target Population to
identify their cultural and linguistic needs in designing and planning for providing
appropriate behavioral health services.
10. Ensure employees attend Cultural Competency, Compliance, and Billing and
Documentation trainings provided by the COUNTY upon hire and annually thereafter
or as needed.
11. Assist with training COUNTY staff and the community in SB163 Wraparound Service
processes and service options.
12. Develop training curriculum, as COUNTY identifies a need.
13. Meet all requirements to become a Short-Doyle Medi-Cal organizational provider for
Specialty Mental Health Services in the Fresno County Mental Health Plan (MHP).
14. Maintain ongoing responsibility for Data and Reporting, including the following:
a. Send applicable information and reports to the following distribution list for
COUNTY staff: DSS Financial Analyst, DSS Contract Analyst, DSS Program
Manager, DSS Social Work Supervisor and DBH Contract Analyst. (actual
names and email addresses to be provided at a later date)
b. Possess the administrative and fiscal capability to provide and manage the
proposed services and ensure a cost-effective service delivery and operational
structure with an audit trail that adheres to Generally Accepted Accounting
Principles.
c. Report on performance measures (utilizing the Monthly Activity Report, identified
in Exhibit H), outcomes, units of service for Medi-Cal and Non Medi-Cal billable
services, cost allocation reports, or other reports as established by COUNTY.
This Agreement will be closely monitored for performance and CONTRACTOR
will be required to report monthly outcomes and expenses.
d. All reports will be due to the County by the 20 th of each month, and be
reviewed for accuracy. (If the 20th lands on a weekend or Holiday, reports will
be due the next business day). Reimbursement for monthly expenses may be
delayed in the event inaccurate reports are submitted.
e. Provide COUNTY with Outcome Reports every six (6) months. Outcome Report
formats will be established through COUNTY/CONTRACTOR collaboration.
Outcome Report measurements may change, based on requirement information
or measurements needed. Current Outcome measurements are listed as follows:
1) Cost Effectiveness, 2) Family Functioning, 3) Prevention of Placements in
More Restrictive Environments, 4) Improvement of Emotional and Behavioral
Adjustment, 5) School Attendance, 6) Academic Performance, 7) Parent or
Caregiver Satisfaction, and 8) Improvement in Family Involvement, Family &
Child Goal Attainment
f. Provide COUNTY with various reports throughout the length of the child's
enrollment in the program; a few of which are standardized and included herein;
Exhibit P "Monthly Progress Report", Exhibit Q "Discharge Presentation", Exhibit
R "Individual Child and Family Plan Presentation Outline", and Exhibit S
"Individual Child and Family Plan (ICFP)"
g. Maintain electronic health records and supply their own personal computers,
Internet access, printers, signature pads and other network devices to meet
statistical reporting requirements, report client and program outcomes and any
State or County data requirements of the Katie A. Implementation Plan.
Exhibit A
Page 4 of 6
CONTRACTOR shall also maintain capability to enter electronic billing claiming
data into COUNTY's Avatar system. A computer with Internet access is required
for office and field-based staff.
15. Cooperate and participate with the COUNTY MHP in Quality Assurance/Improvement
and Utilization Review Programs and grievance procedures, and comply with all final
determinations rendered by COUNTY's Quality Assurance/Improvement and
Utilization Review Programs, unless the decision is reversed on appeal as set forth in
the COUNTY MHP Provider Manual, incorporated herein by this reference.
COUNTY's adverse decisions regarding CONTRACTOR services to clients may
result in the disallowance of payment for services rendered; or may result in additional
controls to the delivery of services; or may result in the termination of this Agreement.
COUNTY shall have sole discretion in the determination of Quality
Assurance/Improvement and Utilization Review outcomes, decisions and actions.
16. Establish criteria and protocols to insure referral to services are therapeutically
appropriate, benefits the client and caregiver, achieves the client's treatment goals
and supports the success of the CWS case plan and avoids any potential for
perceived or actual conflict of interest or self-referral.
17. Maintain responsibility for any court reports and/or necessary testimony:
a. Court Reports -Documented reports of assessment and evaluation findings,
progress in treatment, recommendations for treatment and service plans
regarding reunification, maintenance and termination of parental rights, and
justification for recommendations.
b. Court Testimony -On-site court testimony of assessment and evaluation
findings, treatment and service plan recommendations regarding reunification,
maintenance and termination of parental rights, and justification for
recommendations.
18. Obtain signatures, as required, regarding consent:
a. Care provider can sign for day trips and other minor miscellaneous items.
b. Court Order should suffice for most other items.
19. Upon notification of a pending court hearing, CONTRACTOR agrees to complete and
submit to the COUNTY a "Periodic Review Report" twenty-one (21) calendar days
prior to the court date or seven (7) calendar days after notification.
COUNTY SHALL BE RESPONSIBLE FOR THE FOLLOWING:
COUNTY shall:
1. Designate a contact person for CONTRACTOR to communicate with, when necessary.
2. Meet with CONTRACTOR monthly, or as often as needed, to exchange pertinent
information, resolve problems, and work collaboratively to coordinate services.
3. Include necessary items in initial referral packets, as agreed upon by both
CONTRACTOR and COUNTY. Referral Packets shall include the following
a. A completed referral
b. Placement History
Exhibit A
Page 5 of 6
c. Current court orders -detention minute order (CHOP Medical/Dental)
d. Health and Education Passport (HEP)
e. Mental Health Assessment (including most recent, if available)
f. Team Decision Meeting (TDM)/Staffing notes (if available)
g. Individualized Education Program (IEP} (if available/applicable)
h. JV220 (if applicable)
i. FFA/Group Home Quarterly Report
4. Facilitate Intensive Care Coordination (ICC) meetings initially, and no less than every
ninety (90) days, for a child/youth identified as a Katie A. Subclass client.
5. Organize teaming meetings in alignment with CAPP, SB 163 and Katie A. Core Practice
models for which CONTRACTOR will be required to participate, when appropriate.
6. Provide education and training on CWS, practice models and Medi-Cal licensing,
documentation and billing requirements, as needed.
7. Expedite court processes required to change placements.
8. Screen children and their families for enrollment of Wraparound program. Provide
medication evaluations, ongoing monitoring and comply with State and County
regulations related to the JV220 process or other court requirements, complete
Treatment Authorization Requests (TARs) when ordering psychotropic medications and
coordinate the client care with the therapist and treatment team.
9. Act as liaison between staff and/or representatives of the California Department of Social
Services (COSS) and CONTRACTOR.
1 O. Manage the Wraparound Program trust funds.
11. Monitor this Agreement for achievement of agreed upon outcomes and for compliance
with the specified terms and conditions herein.
12. Through the MHP utilization management and quality improvement process, may be
required to take action necessitating consultation with its Medical Director, or with other
physicians, prior to authorization of MHP Covered Services, or to terminate this
Agreement. In the interest of program integrity or the welfare of clients, COUNTY may
introduce additional utilization controls as may be necessary at any time and without
advance notice to CONTRACTOR. In the event of such change, COUNTY shall notify
CONTRACTOR in writing, and the change shall take effect upon the tenth (10th}
calendar day following the deposit of said notice, by COUNTY, into the United States
mail, postage prepaid, to the address set forth in Section 33 of this Agreement.
13. Notify the CONTRACTOR when court hearings are scheduled.
PERFORMANCE MEASUREMENTS: Under the Katie A. Settlement Agreement and
Implementation Plan, the DHCS and COSS are working to adopt statewide use of a data-
informed system of performance oversight, accountability, and communication that efficiently
Exhibit A
Page 6 of 6
monitors, measures, and evaluates access, quality, satisfaction, effectiveness, costs, and
outcomes at the individual, program, and system levels.
Performance measurements developed by COUNTY will reflect the information required by
DHCS and COSS. Outcome indicators for this Agreement will continue to be developed in
conjunction with CONTRACTOR and State departments.
RFP 952-5322 Page: 1 of27 ExhibitB
Sefla18 B111163 Wraparound and Therapeutic Foster Can, Servlcet
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget-July 1, 2015 to June 30, 2016
Budget Categories • Total Proposed Budget
Non Direct Consumer Cost Direct Consumer Cost
MeC11-ca1 Non MeaH.;a1 Mea1-1.;a1 Non Mea1-1.;a1
Line Item Description (Must be itemized) FTE% Billable Cost Billable Cost Billable Cost Billable Cost Total
PERSONNEL SALARIES:
0001 Title Associate Director 1.00 $61,870 $20,623 $82,493
0002 Title Clinician I 4.00 $144,093 $48,031 $192,124
0003 Title Clinical Director 0.50 $34,147 $11,383 $45,530
0004 Title Community Development Spec (RCL) 1.00 $33,653 $33,653
0005 Title Addiction Prevention Counselor 3.00 $77,222 $25,741 $102,963
0006 Title EducationNocational Specialist 3.00 $77,076 $25,692 $102,768
0007 Title Clinical Program Manager 4.00 $191,145 $63,715 $254,860
0008 Title Facilitator 12.00 $350,118 $116,706 $466,824
0009 Title Family Partner (RCL) 4.00 $135,572 $135,572
0010 Title Family Specialist 22.00 $497,029 $165,677 $662,706
0011 Title Family Services Coordinator: Family Finding 1.00 $30,007 $10,003 $40,010
0012 Title Family Service Coordinator 1.00 $30,007 $10,003 $40,010
0013 Title Program Supervisor 3.00 $115,976 $38,659 $154,635
0014 Title Intake Coordinator 1.00 $29,087 $9,696 $38,783
0015 Title Administrative Assistant II 1.00 $24,914 $8,305 $33,219
0016 Title Billing Specialist 1.00 $23,268 $7,756 $31,024
0017 Title ED, Regional Executive Director 0.45 $39,089 $13,030 $52,119
0018 Title Health Information Management 1.00 $25,596 $8,532 $34,128
0019 Title Learning Partners 1.00 $52,034 $17,345 $69,379
0020 Title Outcomes & Evaluation 0.50 $17,400 $5,800 $23,200
0021 Title Quality Support 0.50 $28,721 $9,574 $38,295
SALARY TOTAL 65.95 $211,022 $70,342 $1,637,777 $715,154 $2,634,295
PAYROLL TAXES:
0030 OASDI old age survivor and disability $13,083 $4,361 $101,542 $44,339 $163,325
0031 FICA/MEDICARE $3.060 $1,020 $23,748 $10,370 $38,198
0032 U.I. $4,959 $1,653 $38,488 $16,806 $61,906
PAYROLL TAX TOTAL $21,102 $7,034 $163,778 $71,515 $263,429
EMPLOYEE BENEFITS:
0040 Retirement $8,441 $2,814 $65,511 $28,606 $105,372
0041 Workers Compensation $6,331 $2,110 $49,133 $21,455 $79,029
0042 Health Insurance (medical vision, life, dental) $23,351 $7,784 $181,235 $79,138 $291,508
EMPLOYEE BENEFITS TOTAL $38,123 $12,708 $295,879 $129,199 $475,909
SALARY & BENEFITS GRAND TOTAL $270,247 $90,084 $2,097,434 $915,868 $3,373,633
Mem-1.,al NOn MeC11-Gal
FACILITIES/EQUIPMENT EXPENSES: Billable Cost Billable Cost Total
1010 Rent/Lease Building 37,917 12,639 $50,556
1011 Rent/Lease Equipment 3,122 1,041 $4,163
1014 Maintenance (facility) 3,342 1,114 $4,456
1017 Other -Depreciation 4,218 1,406 $5,624
FACILITY/EQUIPMENT TOTAL $48,599 $16,200 $64,799
OPERATING EXPENSES:
1060 Telephone $41,127 $13,709 $54,836
1062 Postage/Shipping/Printing 1,426 475 $1,901
1066 Office Supplies & Equipment 4,807 1,602 $6,409
1069 Program Supplies Therapeutic 8,437 2,813 $11,250
1072 Staff Mileage/vehicle maintenance 165,487 55,163 $220,650
1074 Staff Training/Registration 5,011 1,671 $6,682
1076 Other -Emergency Flex Funds 63,000 $63,000
OPERATING EXPENSES TOTAL $226,295 $138,433 $ 364,728
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit 5,453 1,818 7,271
1082 Liability Insurance 17,382 3,030 $20,412
1083 Other Administrative Overhead 485,488 161,829 647,317
FINANCIAL SERVICES TOTAL 508,323 166,677 $675,000
SPECIAL EXPENSES (Consultant/Etc.):
1089 Medication Supports I 16,380 I 5,460 $21,840
SPECIAL EXPENSES TOTAL 16,380 5,460 $21,840
TOTAL PROGRAM EXPENSES $4,500,000
RFP 952-5322 Page: 2 of 27 Exhibit B
&mate 8111183 Wraparound and Therapeutic Foster Care Services
FamiliesFirst, Inc. dba EMQ FamlliesFlrst
Budget· July 1, 2015 to June 30, 2018
VOi/Units OT MeoI-i.,.;aI Non Mem-Cal
DIRECT SERVICE REVENUE: Svc Rate Billable Cost Billable Cost $Amt.
3000 Mental Health Services 94,515 $2.61 $246,684 $246,684
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage 203,298 $2.02 $410,662 $410,662
3200 Crisis Intervention 6,776 $3.88 $26,291 $26,291
3300 Medication Support 13,553 $4.82 $65,325 $65,325
3400 Collateral 27,105 $2.61 $70,744 $70,744
3500 Court Documentation, Report, Appearance $0
3600 Psychological evaluation $0
3700 ICC-Case Management 135,527 $2.02 $273,765 $273,765
3800 IHBS-Rehab 874,149 $2.61 $2,281,529 $2,281,529
3900 SB Non Billable Services 1,022,727 $1.10 $1,125,000 $1,125,000
DIRECT SERVICE REVENUE TOTAL 2,377,650 $ 3,375,000 $ 1,125,000 $4,500,000
OTHER REVENUE:
4000 Other $0
4100 Other $0
4200 Other $0
4300 Other $0
OTHER REVENUE TOTAL $0
TOTAL PROGRAM REVENUE $4,500,000
1,687,500 Medi-Cal Revenue 50% FFP
1,350,000 Medi-Cal Revenue 40% EPSDT (2011 Realignment)
337,500 Medi-Cal Revenue 10% County SB163 Trust Fund
$ 3,375,000 Total Medi-Cal Revenue
1,354,923 Total Medi-Cal Units
$ 2.49 Medi-Cal cost per unit
$1,125,000 Non Medi-Cal Billable Service Cost
1,022,727 Total Non-Medi-Cal Billable units
$ 1.10 Non Medi-Cal cost per unit
Annualized Total Summarv
$Dollar Amoun %Percentaae%
MeC1I-i.,.;aI
Billable Cost $ 3,375,000 75%
, Non Meo1-1.,aI
Billable Cost $ 1,125,000 25%
Total $ 4,500,000
RFP 952-5322 Page: 3 of 27 Exhibit B
Senata Bill 163 Wraparound and Therapeutic Foster care Services
FamiliesFlrst, Inc. dba EMQ FamiliesFlrst
Budget • July 1, 2015 to June 30, 2016
PROPOSED BUDGET DETAIL NARRATIVE
BUDGET NARRATIVE
0001 Associate Director
I Total Amount
$ 82,493
1.0 FTE at a salary of $82,493 = $82,493
Master's degree (MA/MS). Must have appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of California.
Must meet the BBS requirements to provide clinical oversight and supervision with three to ten years of experience in healthcare/psychology/behavioral/mental
health. The Associate Director assists the clinical director with implementing strategies to accomplish the agency annual priorities at the program level. Directs
and develops managers, ensures CPMS are competent and have all tools necessary to lead teams.
0002 Clinician I
I Total Amount
$ 192,124
4.0 FTE at average salary of $48,031 = $192,124
Master's Degree (MA/MS) and at least two years of experience working with youth, young adults and families in a therapeutic environment is required. If
unlicensed must be a registered intern with the Board of Behavioral Sciences and receiving appropriate clinical supervision. Provides psychotherapy and
psychotherapeutic support to children and families.
0003 Clinical Director
I Total Amount
$ 45,530
0.5 FTE at a salary of $91,060 = $45,530
Master's Degree (MA/MS) in Psychology, Social Work, Marriage and Family Counseling or related field required. Must have appropriate license to practice as a
Licensed Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to provide clinical oversight and
supervision. Provides regional leadership and effectively manages, develops, maintains, monitors and ensures the clinical quality in multiple clinical programs.
0004 Community Development Specialist (RCL)
I Total Amount
$ 33,653
1.0 FTE at a salary of $33,653 = $33,653
Bachelor's Degree (BA/ BS) in Marketing or related field preferred. The community development specialist develops resources that support the needs of young
people and families receiving agency services. Inspires and ensures community engagement in therapeutic and strength based opportunities to enhance or
create mental health programs.
0005 Addiction Prevention Counselor
I Total Amount
$ 102,963
3.0 FTE at an average salary of $34,321 $102,963
Bachelor's degree (BA/ BS) or higher in Psychology, Counseling or Social Work; certified drug and alcohol counselor is preferred. Two to four years related
experience or an equivalent combination of education and experience working with youth or young adults with co-occurring disorders.
0006 Education/Vocational Specialist
I Total Amount
$ 102,768
3.0 FTE at an average salary of $34,256 = $102,768
Associate's Degree (AA/ AS) AND six (6) years related experience in a mental
health/education/vocational setting required.
• OR Bachelor's Degree (BA/BS) AND four (4) years related experience in a mental
health/education/vocational setting required.
• OR Master's Degree (MA/ MS) in a mental health related field AND two (2) years related experience in a mental health setting required.
RFP 952-5322 Page: 4 of27 ExhibitB
. .. ·· Senate Bill 163 Wraparound and Therapeutic Foster Care Servlcea
FamillesFirst, Inc. dba EMQ FamiliesFirst
' Budget· July 1, 2015 to June 30, 2016
0007 Clinical Program Manager
I Total Amount
$ 254,860
4.0 FTE at an average salary of $63,715 = $254,860
Master's degree (MA/MS) required in a related field; two to four years related experience. Must have appropriate license to practice as a Licensed Clinical
Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to provide clinical oversight and supervision. Hires,
develops, trains, manages and retains clinical program staff.
0008 Facilitator
I Total Amount
$ 466,824
12.0 FTE at an average salary of $38,902 = $466,824
Master's Degree (MS/ MA) in Psychology, Social Work, Counseling or related field required. Works in the family's home and a variety of community and/or
treatment settings, coordinates services with an understanding of the complexity of each family while blending the clinical care of the youth with the facilitation
of the life domain planning process.
0009 Family Partner (RCL)
I Total Amount
$ 13S,572
4.0 FTE at an average salary of $33,893 $135,572
High School Diploma or General Education Development (GED) required; some college education is preferred. Three years of experience as a parent or caregiver
of child with special needs. Implements family friendly practices by providing a parent's perspective to the routine operations and developments of programs.
0010 Family Specialist
I Total Amount
$ 662,706
22.0 FTE at an average salary of $30,123 = $662,706
Bachelor's degree (BA/BS) required; six months, one year, or two years of experience working with SEO children required, dependent upon connect, OR
equivalent combination of education and experience. Develops a strength based relationship with youth and caregivers in order to intervene with maladaptive
behaviors while developing the youths strengths and interests.
0011 Family Service Coordinator: Family Finding
I Total Amount
$ 40,010
1.0 FTE at a salary of $40,010 = $40,010
Associate's degree (AA/AS) and six years of experience or Bachelor's degree (BNBS) with four years of experience or Master's degree (MA/MS) with two years
of experience in related field is required. Works independently in family homes and a variety of community and/or treatment settings directly with children and
adults. Is responsible for developing and coordinating family-centered teams.
0012 Family Services Coordinator
I Total Amount
$ 40,010
1.0 FTE at an average salary of $40,010 $40,010
Associate's degree (AA/AS) and six years of experience or Bachelor's degree (BA/BS) with four years of experience or Master's degree (MA/MS) with two years
of experience in related field is required. Works independently in family homes and a variety of community and/or treatment settings directly with children and
adults. Is responsible for developing and coordinating family-centered teams.
0013 Program Supervisor
I Total Amount
$ 154,63S
3.0 FTE at an average salary of $51,54S = $154,635
Bachelor's Degree (BA/ BS) in Psychology, Social Work, Counseling, Education or related field. Minimum of three (3) years of experience in social or mental
health services delivery, residential care supervision or education required. Hires, develops, trains and manages program staff. Coordinates and supervises daily
program operations.
0014 Intake Coordinator
I Total Amount
$ 38,783
1.0 FTE at a salary of $38,783 = $38,783
Bachelor's degree (BA) in social work, psychology, marriage, child and family counseling, counseling psychology; minimum of two years of experience working
with dependent children is required. This position is responsible for placement of clients into the program.
RFP 952-5322 Page: 5 of 27 ExhibitB
•
., .· Senate BUI 163 Wraparound and Therapeutic Foster Care Services
FamillesFirst, Inc. dba EMQ FamiliesFirst
.. {~;,;.' \< ... / .. ' Budget· Jwv1,2015toJune30,2016
0015 Administrative Assistant II
I Total Amount
$ 33,219
1.0 FTE at a salary of $33,219 = $33,219
High school diploma, GED or equivalent combination of education and experience required. The administrative assistant II provides administrative support to
program staff; performs private insurance billing and handles all flex funds for the Wrap program.
0016 Billing Specialist
I Total Amount
$ 31,024
1.0 FTE at an average salary of $31,024 = $31,024
High school diploma, GED or equivalent combination of education and experience required. This position inputs the EPSDT billing into Avatar along with
reconciliation and preparation of claim certification and inputs the units and flex funds on SB163 invoice.
0017 ED, Regional Executive Director
I Total Amount
$ 52,119
0.45 FTE at a salary of $115,818 $52,119
Master's Degree (MA/MS) in Psychology, Social Work, Marriage and Family Counseling, Administration, Business or related field is required. Must have
appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to
provide clinical oversight and supervision. This position provides leadership, strategic direction and operational oversight. This position provides leadership,
strategic direction and operational oversight.
0018 Health Information Management
I Total Amount
$ 34,128
1.0 FTE at a salary of $34,128 = $34,128
Associates degree (AA/AS) required with one year direct work experience. Database, Visual Basic, and/or Crystal Reports experience required. Basic knowledge
of legal issues regarding releases of information and other medical records issues required. Technical training on report writing in a database environment
required.
0019 Learning Partners
I Total Amount
$ 69,379
1.0 FTE at an average salary of $69,379 = $69,379
Bachelor's Degree (BA/BS) or equivalent experience in related field required. Two years of experience in education/learning/training. Assesses learning needs,
designs, develops and presents leanin~ activities.
0020 Outcomes Evaluation
I Total Amount
$ 23,200
0.5 FTE at a salary of $46,400 = $23,200
Bachelor's degree (BA/BS) required with six years research experience with statistical analysis software, database development, management, merging of
multiple databases. Four (4) years of related experience in literature review, program research, data collection, intermediate-advanced evaluation, and
advanced knowledge and usage of statistical software package. Minimum of one (1) year experience in training research activities and lead responsibilities in
research projects.
0021 Quality Support
I Total Amount
$ 38,295
o.s FTE at a salary of $76,589 = $38,295
Master's Degree (MA/ MS) in Psychology, Social Work, Marriage and Family
Counseling or related field required. Must have appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of
California. Must meet the BBS requirements to provide clinical oversight and supervision. Develops, maintains, and manages operational infrastructure
functions that provide support to service delivery (intake, medical records), the assurance of quality (utilization review and quality and manages operational
infrastructure functions that provide support to service delivery (intake, medical records), the assurance of quality (utilization review and quality assurance
structures, training structures, outcomes evaluation structures, risk management oversight) for a distinct geographic region in compliance with agency
standards.
0030OASDI
I Total Amount
$ 163,325
Calculated at 6.2% of salaries.
I Total Amount
RFP 952-5322 Page: 6 of27 ExhibitB
L---.', ,,,, .. i,· '< ,, .. . · Senate 8111163 Wraparound and Therapeutic Foeter Care services
FamiliesFirst, Inc. dba EMQ FamlliesFirst
Budget-July 1, 2015 to June 30, 2016
0031 FICA/MEDICARE Is 38,198
Calculated at 1.45% of salaries.
0032 UI
I Total Amount
$ 61,906
Calculated at 2.35% of salaries.
0040 Retirement
I Total Amount
$ 105,372
Calculated at 4.0% of salaries.
0041 Workers Compensation
I Total Amount
$ 79,029
Calculated at 3.0% of salaries.
0042 Health insurance (medical, vision, life, dental)
I Total Amount
$ 291,508
Calculated at approximately 11% of salaries.
1010 Rent/Lease Building
I Total Amount
$ 50,556
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes building, storage and file storage unit rental payments and all the costs associated with storing and retrieving of
client, personnel or other files or records.
1011 Rent/Lease Equipment
I Total Amount
$ 4,163
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes rental payments for equipment including leased copiers, faxes, postage machines, phone systems, laptops or
other communication, office or facility equipment.
1014 Maintenance (facility)
I Total Amount
$ 4,456
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This Includes common area maintenance on leased building charges, maintenance/building repair charges, HVAC
maintenance and repair, landscaping, janitorial services, confidential paper shredding services, in-house or outside equipment repair and labor.
I Total Amount
1017 Other-Depreciation $ 5,624
Depreciation includes deprecation on leasehold improvements, office furniture/fixtures and equipment meeting amortization thresholds. Costs are allocated
between programs on the basis of payroll dollars and have been estimated based on historical trends.
I Total Amount
1060 Telephone $ 54,836
Cell phones, Land lines, DSL, fax charges, phone system; also wireless cards for laptop computers enabling us to maintain a fully functional mobile work force to
deliver in-home services. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
RFP 952-5322 Page: 7 of27 ExhibitB
\i ,,,,,J,iL;/'• .. ,; .. ,,_, + '•·" Senate 8111163 Wraparound and Therapeutic Foeter Care Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget• July 1, 2015 to June 30, 2016
1062 Postage/Shipping/Printing
I Total Amount
$ 1,901
Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
1066 Office Supplies & Equipment
I Total Amount
$ 6,409
Office supplies and equipment include, but are not limited to: paper, pens, files, staplers, break rooms supplies such as coffee, paper cups, plastic utensils are
also included. Costs are allocated between programs on the basis of direct labor dollars and have been estimated based on historical trends.
1069 Program Supplies-Therapeutic
I Total Amount
$ 11,250
Includes those supplies utilized in the direct delivery of therapeutic services to clients. Cost is estimated to be approximately $15.00 per direct care staff per
month. Materials, cash payments, outing costs, etc. used to motivate or reinforce desired behavior.
1072 Staff Mileage/vehicle maintenance
I Total Amount
$ 220,650
Primarily includes mileage reimbursement paid (at the current federal rate to staff supporting program or program related activities. In addition, a component
of travel costs may include overnight travel by staff for training, meetings or conferences. This figure also takes into consideration that we anticipate that the
majority of all program services will be delivered in the community. Also includes the transportation of clients. Costs are estimated to be approximately 9.38%
of direct personnel costs prior to taxes and benefits.
1074 Staff Training/ Registration
I Total Amount
$ 6,682
Includes ongoing training in the Wraparound model of care, organizational tools, team/organizational psychology, philosophy of client based services,
integration of roles/team dynamics, assessment and individualized treatment planning, general services, organized admissions, and individualized treatment
planning associated with the Wraparound system of care. Also includes other mandatory trainings such as first aid and CPR.
1076 Other -Emergency Flex Funds
I Total Amount
$ 63,000
Cost of "whatever it takes" flexible funding for client needs to maintain growth, functioning and recovery. Flexible funds were budgeted at $35 per client per
month. Requests above $300 are approved by the Wraparound Community Team.
1081 External Audit
I Total Amount
$ 7,271
Includes annual audit insuring all financial records are relevant and accurate and in compliance with state and federal laws and regulations. Audit costs are
allocated between programs on the basis of payroll dollars and have been estimated based on historical costs.
1082 liability Insurance
I Total Amount
$ 20,412
Includes general business liability and property coverage along with professional liability insurance.
RFP 952-5322 Page: 8 of27 ExhibitB
. · .. ...... ·; '•· , .. · .. ·:···.',' '' ,-; · · Senate BUI 163 Wraparound and Therapeutic Foster Care Services
FamillesFirst, Inc. dba EMQ FamlliesFirst
Budget· July 1, 2016 to June 30, 2016
1083 Other-Administrative Overhead
I Total Amount
$ 647,317
Represents the indirect costs of the agency's general and administrative shared support services such as finance, accounting, billing, human resources, clinical
administration, information technology, quality assurance and outcomes/evaluation, insurance, professional fees, HIPAA compliance and clinical record audits,
quality management oversight of Medi-Cal records, risk management and program fidelity, recruiting and human resources support, MIS infrastructure & QI/UM
department support and oversight as well as executive management. Costs that cannot be specifically charged to a program are allocated to programs on the
basis of direct labor program costs prior to the addition of taxes and benefits. Indirect costs have been budgeted at 15% of program costs.
1089 Medication Supports
I Total Amount
$ 21,840
This is a contract position estimated at to cost $175 per hour. The psychiatrist will be required to provide 2.61 hours per week, or approximately 10.44 hours
per month ($1,820 per month x 12 months= $21,840) and will provide medical oversight/supervision of program services.
3000-3900 Medi-Cal Revenues I Total Amount
$ 4,500,000
Medi-Cal eligibility is estimated to be 90% of all clients served. For the purpose of a conservative revenue projection, only the clinicians, facilitators and family
specialists were assumed to be billable positions. Blend of service and unit volume are based on EMQ FamiliesFirst's experience in delivering mental health
services in its existing Wraparound program. This budget assumes full staff and full census on day one and projects Medi-Cal revenue generation of $3,375,000
for the initial 12 month period. These revenue figures are based on a case management rate of $2.02 per minute, a mental health rate of $2.61 per minute, a
medication support rate of $4.82 per minute, a collateral rate of $2.61 per minute and a crisis intervention rate of $3.88 per minute. The blend of services is
anticipated to be 7% case management, 15% mental health, 1% crisis intervention, 1% medication support, 2% collateral, 10% ICC-case management, 64% IBHS·
rehab.
RFP 952-5322
; ,. •·· .; ·.
Page: 9 of27
Sena BIH 163 Wraparound and Therapeutic Foatar Care Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget-July1,2011toJune30,2016
ExhibitB
It is recognized that overhead cost is part of every organizations cost of doing business to evaluate direct service cost versus overhead
cost, please utilize this page to delineate what makes up your agencies overhead.
Below is an example of overhead cost components/categories, please feel free to adjust to best represent your agency
Cost Cateaories
Accountina/Finance
Human Resources
Information Tech.
Executive ManaQement
Training
/Quality/Compliance
Total
Amount Reauested
129,463
129,463
194,195
97,098
97,098
647,317
Exolanation
Agency corporate
general accounting
and financial
services
Agency human
resources and
administration,
including recruiting,
training and
employee
development
Agency network,
communication,
security,
application
development and
maintenance
Agency
management and
leadership and
administration
Agency corporate
training, quality,
and compliance
requirements
1) Please provide your agency's total administrative overhead cost. $13,000,000
2) Please provide the percentage of your agency's total administrative overhead cost, as is it relates to your total agency cost. 15%
3) Please indicate your agency's proposed total cost for this service component. $4,500,000
4) Please indicate the percentage of your agency's administrative overhead cost charge, as it relates to the total cost proposed for this
service component. 15%
5) Please indicate the percentage of the total agency's administrative overhead cost, charged under this service component as it relates
to your agency's total administrative cost. 5%
RFP 952-5322 Page: 10 of 27 ExhibitB
: ·• .'.. ... .. . ·· . ' -.,. · Senate BUI 163 Wraparound and Therapautlc Foster Care Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget· July 1, 2016 to June 30, 2017
Budget Categories -Total Proposed Budget
Non Direct Consumer Cost Direct Consumer Cost
MeaH;aI Non MeaI-La1 MeelI-Lal Non MeaH..;a1
Line Item Description (Must be itemized) FTE% Billable Cost Billable Cost Billable Cost Billable Cost Total
PERSONNEL SALARIES:
0001 Title Associate Director 1.00 $61,870 $20,623 $82,493
0002 Title Clinician I 4.00 $144,093 $48,031 $192,124
0003 Title Clinical Director 0.50 $34,147 $11,383 $45,530
0004 Title Community Development Spec (RCL) 1.00 $33,653 $33,653
0005 Title Addiction Prevention Counselor 3.00 $77,222 $25,741 $102,963
0006 Title EducationNocational Specialist 3.00 $77,076 $25,692 $102,768
0007 Title Clinical Program Manager 4.00 $191,145 $63,715 $254,860
0008 TiUe Facilitator 12.00 $350,118 $116,706 $466.824
0009 Title Family Partner (RCL) 4.00 $135,572 $135,572
0010 Title Family Specialist 22.00 $497,029 $165,677 $662,706
0011 Title Family Services Coordinator: Family Finding 1.00 $30,007 $10,003 $40,010
0012 Title Family Service Coordinator 1.00 $30,007 $10,003 $40,010
0013 Title Program Supervisor 3.00 $115,976 $38,659 $154,635
0014 Title Intake Coordinator 1.00 $29,087 $9,696 $38,783
0015 Title Administrative Assistant II 1.00 $24,914 $8,305 $33,219
0016 Title Billing Specialist 1.00 $23,268 $7,756 $31,024
0017 Title ED, Regional Executive Director 0.45 $39,089 $13,030 $52,119
0018 Title Health Information Management 1.00 $25,596 $8,532 $34,128
0019 Title Learning Partners 1.00 $52,034 $17,345 $69,379
0020 Title Outcomes & Evaluation 0.50 $17,400 $5,800 $23,200
0021 Title Quality Support 0.50 $28,721 $9,574 $38,295
SALARY TOTAL 65.95 $211,022 $70,342 $1,637,777 $715,154 $2,634,295
PAYROLL TAXES:
0030 OASDI old age survivor and disability $13,083 $4,361 $101,542 $44,339 $163,325
0031 FICA/MEDICARE $3,060 $1,020 $23,748 $10,370 $38,198
0032 U.I. $4,959 $1,653 $38,488 $16,806 $61,906
PAYROLL TAX TOTAL $21,102 $7,034 $163,778 $71,515 $263,429
EMPLOYEE BENEFITS:
0040 Retirement $8,441 $2,814 $65,511 $28,606 $105,372
0041 Workers Compensation $6,331 $2,110 $49,133 $21,455 $79,029
0042 Health Insurance (medical vision, life, dental) $23,351 $7,784 $181,235 $79,138 $291,508
EMPLOYEE BENEFITS TOTAL $38,123 $12,708 $295,879 $129,199 $475,909
SALARY & BENEFITS GRAND TOTAL $270,247 $90,084 $2,097,434 $915,868 $3,373,633
MeC1I-t;al Non Meel1-1.,a1
FACILITIES/EQUIPMENT EXPENSES: Billable Cost Billable Cost Total
1010 Rent/Lease Building 37,917 12,639 $50,556
1011 Rent/Lease Equipment 3,122 1,041 $4,163
1014 Maintenance (facility) 3,342 1,114 $4,456
1017 Other -Deoreciation 4,218 1,406 $5,624
FACILITY/EQUIPMENT TOTAL $48,599 $16,200 $64,799
OPERA TING EXPENSES:
1060 Telephone $41,127 $13,709 $54,836
1062 Postage/Shipping/Printing 1,426 475 $1,901
1066 Office Supplies & Equipment 4,807 1,602 $6,409
1069 Program Supplies -Therapeutic 8,437 2,813 $11,250
1072 Staff Mileage/vehicle maintenance 165,487 55,163 $220,650
1074 Staff Training/Registration 5,011 1,671 $6,682
1076 Other Emergency Flex Funds 63,000 $63,000
OPERATING EXPENSES TOTAL $226,295 $138,433 $ 364,728
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Auel it 5,453 1,818 7,271
1082 Liability Insurance 17,382 3,030 $20,412
1083 Other -Administrative Overhead 485,488 161,829 647,317
FINANCIAL SERVICES TOTAL 508,323 166,677 $675,000
SPECIAL EXPENSES (Consultant/Etc.}:
1089 Medication Supports I 16,380 I 5,460 $21,840
SPECIAL EXPENSES TOTAL 16,380 5,460 $21,840
TOTAL PROGRAM EXPENSES $4,500,000
RFP 952-5322 Page: 11 of 27 ExhibitB
-,··· : ' S.nate B11163 Wraparound and Th.,..peutfc Foster care Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
· Budget -July 1, 2016 to June 30, 2017
VOI/UnttS OT Mea1-1..,aI NOn Mem-Gal
DIRECT SERVICE REVENUE: Svc Rate Billable Cost Billable Cost $Amt.
3000 Mental Health Services 94,515 $2.61 $246,684 $246,684
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, linkage/Brokerage 203,298 $2.02 $410,662 $410,662
3200 Crisis Intervention 6,776 $3.88 $26,291 $26,291
3300 Medication Support 13,553 $4.82 $65,325 $65,325
3400 Collateral 27,105 $2.61 $70,744 $70,744
3500 Court Documentation, Report. Appearance $0
3600 Psychological evaluation $0
3700 ICC-Case Management 135,527 $2.02 $273,765 $273,765
3800 IHBS-Rehab 874,149 $2.61 $2,281,529 $2,281,529
3900 SB Non Billable Services 1,022,727 $1.10 $1,125,000 $1,125,000
DIRECT SERVICE REVENUE TOTAL 2,377,650 $ 3,375,000 $ 1,125,000 $4,500,000
OTHER REVENUE:
4000 Other $0
4100 Other $0
4200 Other $0
4300 Other $0
OTHER REVENUE TOTAL $0
TOTAL PROGRAM REVENUE $4,500,000
1,687,500 Medi-Cal Revenue 50% FFP
1,350,000 Medi-Cal Revenue 40% EPSDT (2011 Realignment)
337,500 Medi-Cal Revenue 10% County SB163 Trust Fund
$ 3,375,000 Total Medi-Cal Revenue
1,354,923 Total Medi-Cal Units
$ 2.49 Medi-Cal cost per unit
$1,125,000 Non Medi-Cal Billable Service Cost
1,022,727 Total Non-Medi-Cal Billable units
$ 1.10 Non Medi-Cal cost per unit
Annualized Total Summary
$Dollar Amoun %Percentaae%
Mea1-1..,aI
Billable Cost $ 3,375,000 75%
Non MeaH..;aI
Billable Cost $ 1,125,000 25%
Total $ 4,500,000
RFP 952-5322 Page: 12 of 27 ExhibitB
c; . ' . ·. Senate 8111163 Wraparound and Therapeutic Foster care Servtcea
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget-July 1, 2016to June 30, 2017
PROPOSED BUDGET DETAIL NARRATIVE
BUDGET NARRATIVE
0001 Associate Director
I Total Amount
$ 82,493
1.0 FTE at a salary of $82,493 = $82,493
Master's degree (MA/MS). Must have appropriate license to practice as a licensed Clinical Social Worker or Marriage Family Therapist in the State of California.
Must meet the BBS requirements to provide clinical oversight and supervision with three to ten years of experience in healthcare/psychology/behavioral/mental
health. The Associate Director assists the clinical director with implementing strategies to accomplish the agency annual priorities at the program level. Directs
and develops managers, ensures CPMS are competent and have all tools necessary to lead teams.
0002 Clinician I
I Total Amount
$ 192,124
4.0 FTE at average salary of $48,031 $192,124
Master's Degree (MA/MS) and at least two years of experience working with youth, young adults and families in a therapeutic environment is required. If
unlicensed must be a registered intern with the Board of Behavioral Sciences and receiving appropriate clinical supervision. Provides psychotherapy and
psychotherapeutic support to children and families.
0003 Clinical Director
I Total Amount
$ 45,530
0.5 FTE at a salary of $91,060 $45,530
Master's Degree (MA/MS) in Psychology, Social Work, Marriage and Family Counseling or related field required. Must have appropriate license to practice as a
Licensed Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to provide clinical oversight and
supervision. Provides regional leadership and effectively manages, develops, maintains, monitors and ensures the clinical quality in multiple clinical programs.
0004 Community Development Specialist (RCL)
I Total Amount
$ 33,653
1.0 FTE at a salary of $33,653 = $33,653
Bachelor's Degree (BA/ BS) in Marketing or related field preferred. The community development specialist develops resources that support the needs of young
people and families receiving agency services. Inspires and ensures community engagement in therapeutic and strength based opportunities to enhance or
create mental health programs.
0005 Addiction Prevention Counselor
I Total Amount
$ 102,963
3.0 FTE at an average salary of $34,321 = $102,963
Bachelor's degree (BA/ BS) or higher in Psychology, Counseling or Social Work; certified drug and alcohol counselor is preferred. Two to four years related
experience or an equivalent combination of education and experience working with youth or young adults with co-occurring disorders.
0006 Education/Vocational Specialist
I Total Amount
$ 102,768
3.0 FTE at an average salary of $34,256 = $102,768
Associate's Degree (AA/ AS) AND six (6) years related experience in a mental
health/education/vocational setting required.
• OR Bachelor's Degree (BA/BS) AND four (4) years related experience in a mental
health/education/vocational setting required.
• OR Master's Degree (MA/ MS) in a mental health related field AND two (2) years related experience in a mental health setting required.
RFP 952-5322 Page: 13 of 27 ExhibitB
Senate BID 163 Wraparound and Therapeutic foster Care Service$
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget· July 1, 2016 to June 30, 2017
0007 Clinical Program Manager
I Total Amount
$ 254,860
4.0 FTE at an average salary of $63,715 = $254,860
Master's degree (MA/MS) required in a related field; two to four years related experience. Must have appropriate license to practice as a licensed Clinical
Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to provide clinical oversight and supervision. Hires,
develops, trains, manages and retains clinical program staff.
0008 Facilitator
I Total Amount
$ 466,824
12.0 FTE at an average salary of $38,902 = $466,824
Master's Degree (MS/ MA) in Psychology, Social Work, Counseling or related field required. Works in the family's home and a variety of community and/or
treatment settings, coordinates services with an understanding of the complexity of each family while blending the clinical care of the youth with the facilitation
of the life domain planning process.
0009 Family Partner (RCL)
I Total Amount
$ 135,572
4.0 FTE at an average salary of $33,893 = $135,572
High School Diploma or General Education Development (GED) required; some college education is preferred. Three years of experience as a parent or caregiver
of child with special needs. Implements family friendly practices by providing a parent's perspective to the routine operations and developments of programs.
0010 Family Specialist
I Total Amount
$ 662,706
22.0 FTE at an average salary of $30,123 = $662,706
Bachelor's degree (BA/BS) required; six months, one year, or two years of experience working with SED children required, dependent upon connect, OR
equivalent combination of education and experience. Develops a strength based relationship with youth and caregivers in order to intervene with maladaptive
behaviors while developing the youths strengths and interests.
0011 Family Service Coordinator: Family Finding
I Total Amount
$ 40,010
1.0 FTE at a salary of $40,010 = $40,010
Associate's degree (AA/AS) and six years of experience or Bachelor's degree (BA/BS) with four years of experience or Master's degree (MA/MS) with two years
of experience in related field is required. Works independently in family homes and a variety of community and/or treatment settings directly with children and
adults. Is responsible for developing and coordinating family-centered teams.
0012 Family Services Coordinator
I Total Amount
$ 40,010
1.0 FTE at an average salary of $40,010 = $40,010
Associate's degree (AA/AS) and six years of experience or Bachelor's degree (BA/BS) with four years of experience or Master's degree (MA/MS) with two years
of experience in related field is required. Works independently in family homes and a variety of community and/or treatment settings directly with children and
adults. Is responsible for developing and coordinating family-centered teams.
0013 Program Supervisor
I Total Amount
$ 154,635
3.0 FTE at an average salary of $51,545 = $154,635
Bachelor's Degree (BA/ BS) in Psychology, Social Work, Counseling, Education or related field. Minimum of three (3) years of experience in social or mental
health services delivery, residential care supervision or education required. Hires, develops, trains and manages program staff. Coordinates and supervises daily
program operations.
0014 Intake Coordinator
I Total Amount
$ 38,783
1.0 FTE at a salary of $38,783 = $38,783
Bachelor's degree (BA) in social work, psychology, marriage, child and family counseling, counseling psychology; minimum of two years of experience working
with dependent children is required. This position is responsible for placement of clients into the program.
RFP 952-5322 Page: 14 of 27 Exhibits
' ., Senate Bill 163 Wraparound and Therapeutic Foster Care Services
FamlliesFirst, Inc. dba EMQ FamiliesFirst
,. .. ·''······ Budget-July 1, 2018 to June 30, 2017
0015 Administrative Assistant II
I Total Amount
$ 33,219
1.0 FTE at a salary of $33,219 = $33,219
High school diploma, GED or equivalent combination of education and experience required. The administrative assistant II provides administrative support to
program staff; performs private insurance billing and handles all flex funds for the Wrap program.
0016 Billing Specialist
I Total Amount
$ 31,024
1.0 FTE at an average salary of $31,024 = $31,024
High school diploma, GED or equivalent combination of education and experience required. This position inputs the EPSDT billing into Avatar along with
reconciliation and preparation of claim certification and inputs the units and flex funds on SB163 invoice.
0017 ED, Regional Executive Director
I Total Amount
$ 52,119
0.45 FTE at a salary of $115,818 $52,119
Master's Degree (MA/MS) in Psychology, Social Work, Marriage and Family Counseling, Administration, Business or related field is required. Must have
appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to
provide clinical oversight and supervision. This position provides leadership, strategic direction and operational oversight. This position provides leadership,
strategic direction and operational oversight.
0018 Health Information Management
I Total Amount
$ 34,128
1.0 FTE at a salary of $34,128 = $34,128
Associates degree (AA/AS) required with one year direct work experience. Database, Visual Basic, and/or Crystal Reports experience required. Basic knowledge
of legal issues regarding releases of information and other medical records issues required. Technical training on report writing in a database environment
required.
0019 Learning Partners
I Total Amount
$ 69,379
1.0 FTE at an average salary of $69,379 = $69,379
Bachelor's Degree (BA/BS) or equivalent experience in related field required. Two years of experience in education/learning/training. Assesses learning needs,
desil!ns, develops and presents leaninl! activities.
0020 Outcomes Evaluation
I Total Amount
$ 23,200
0.5 FTE at a salary of $46,400 = $23,200
Bachelor's degree (BA/BS) required with six years research experience with statistical analysis software, database development, management, merging of
multiple databases. Four (4) years of related experience in literature review, program research, data collection, intermediate-advanced evaluation, and
advanced knowledge and usage of statistical software package. Minimum of one (1) year experience in training research activities and lead responsibilities in
research projects.
0021 Quality Support
I Total Amount
$ 38,295
0.5 FTE at a salary of $76,589 = $38,295
Master's Degree (MA/ MS) in Psychology, Social Work, Marriage and Family
Counseling or related field required. Must have appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of
California. Must meet the BBS requirements to provide clinical oversight and supervision. Develops, maintains, and manages operational infrastructure
functions that provide support to service delivery (intake, medical records), the assurance of quality {utilization review and quality and manages operational
infrastructure functions that provide support to service delivery (intake, medical records), the assurance of quality (utilization review and quality assurance
structures, training structures, outcomes evaluation structures, risk management oversight) for a distinct geographic region in compliance with agency
standards.
0030OASDI
I Total Amount
$ 163,325
Calculated at 6.2% of salaries.
I Total Amount
RFP 952-5322 Page: 15 of 27 Exhibit B
.. ··.·' .·· > .. · .• · Senate Biil 163 Wraparound and Therapeutic Foster Care Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget· July 1, 2016 to June 30, 2017
0031 FICA/MEDICARE I $ 38,198
Calculated at 1.45% of salaries.
0032 UI
I Total Amount
$ 61,906
Calculated at 2.35% of salaries.
0040 Retirement
I Total Amount
$ 105,372
Calculated at 4.0% of salaries.
I Total Amount
0041 Workers Compensation $ 79,029
Calculated at 3.0% of salaries.
0042 Health insurance (medical, vision, life, dental)
I Total Amount
$ 291,508
Calculated at approximately 11% of salaries.
1010 Rent/Lease Building
I Total Amount
$ 50,556
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes building, storage and file storage unit rental payments and all the costs associated with storing and retrieving of
client, personnel or other files or records.
1011 Rent/Lease Equipment
I Total Amount
$ 4,163
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes rental payments for equipment including leased copiers, faxes, postage machines, phone systems, laptops or
other communication, office or facility equipment.
1014 Maintenance (facility)
I Total Amount
$ 4,456
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes common area maintenance on leased building charges, maintenance/building repair charges, HVAC
maintenance and repair, landscaping, janitorial services, confidential paper shredding services, in-house or outside equipment repair and labor.
1017 Other-Depreciation
I Total Amount
$ 5,624
Depreciation includes deprecation on leasehold improvements, office furniture/fixtures and equipment meeting amortization thresholds. Costs are allocated
between programs on the basis of payroll dollars and have been estimated based on historical trends.
1060 Telephone
I Total Amount
$ 54,836
Cell phones, Land Lines, DSL, fax charges, phone system; also wireless cards for laptop computers enabling us to maintain a fully functional mobile work force to
deliver in-home services. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
RFP 952-5322 Page: 16 of 27 Exhibit B
•. <' . ....
' Senabt BHI 163 Wraparound and Therapeutic Foster Cant Services .
FamiliesFirst, Inc. dba EMQ FamlliesFirst
Budget • July 1, 2016 to June 30, 2017
1062 Postage/Shipping/Printing
I Total Amount
$ 1,901
Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
1066 Office Supplies & Equipment
I Total Amount
$ 6,409
Office supplies and equipment include, but are not limited to: paper, pens, files, staplers, break rooms supplies such as coffee, paper cups, plastic utensils are
also included. Costs are allocated between programs on the basis of direct labor dollars and have been estimated based on historical trends.
1069 Program Supplies· Therapeutic
I Total Amount
$ 11,250
Includes those supplies utilized in the direct delivery of therapeutic services to clients. Cost is estimated to be approximately $15.00 per direct care staff per
month. Materials, cash payments, outing costs, etc. used to motivate or reinforce desired behavior.
1072 Staff Mileage/vehicle maintenance
I Total Amount
$ 220,650
Primarily includes mileage reimbursement paid (at the current federal rate to staff supporting program or program related activities. In addition, a component
of travel costs may include overnight travel by staff for training, meetings or conferences. This figure also takes into consideration that we anticipate that the
majority of all program services will be delivered in the community. Also includes the transportation of clients. Costs are estimated to be approximately 9.38%
of direct personnel costs prior to taxes and benefits.
1074 Staff Training/ Registration
I Total Amount
$ 6,682
Includes ongoing training in the Wraparound model of care, organizational tools, team/organizational psychology, philosophy of client based services,
integration of roles/team dynamics, assessment and individualized treatment planning, general services, organized admissions, and individualized treatment
planning associated with the Wraparound system of care. Also includes other mandatory trainings such as first aid and CPR.
1076 Other -Emergency Flex Funds
I Total Amount
$ 63,000
Cost of "whatever it takes" flexible funding for client needs to maintain growth, functioning and recovery. Flexible funds were budgeted at $35 per client per
month. Requests above $300 are approved by the Wraparound Community Team.
1081 External Audit
I Total Amount
$ 7,271
Includes annual audit insuring all financial records are relevant and accurate and in compliance with state and federal laws and regulations. Audit costs are
allocated between programs on the basis of payroll dollars and have been estimated based on historical costs.
1082 Liability Insurance
I Total Amount
$ 20,412
Includes general business liability and property coverage along with professional liability insurance.
RFP 952-5322 Page: 17 of 27 Exhibit B
::· ' 'Senate em 163 Wraparound and Therapeutic Foster Care Services
Familiesfirst, Inc. dba EMQ Familiesfirst
Budget-July 1, 2016 to June 30, 2017
1083 Other-Administrative Overhead
I Total Amount
$ 647,317
Represents the indirect costs of the agency's general and administrative shared support services such as finance, accounting, billing, human resources, clinical
administration, information technology, quality assurance and outcomes/evaluation, insurance, professional fees, HIPAA compliance and clinical record audits,
quality management oversight of Medi-Cal records, risk management and program fidelity, recruiting and human resources support, MIS infrastructure & QI/UM
department support and oversight as well as executive management. Costs that cannot be specifically charged to a program are allocated to programs on the
basis of direct labor program costs prior to the addition of taxes and benefits. Indirect costs have been budgeted at 15% of program costs.
1089 Medication Supports
I Total Amount
$ 21,840
This is a contract position estimated at to cost $175 per hour. The psychiatrist will be required to provide 2.61 hours per week, or approximately 10.44 hours
per month ($1,820 per month x 12 months= $21,840) and will provide medical oversight/supervision of program services.
3000-3900 Medi-Cal Revenues I Total Amount
$ 4,500,000
Medi-Cal eligibility is estimated to be 90% of all clients served. For the purpose of a conservative revenue projection, only the clinicians, facilitators and family
specialists were assumed to be billable positions. Blend of service and unit volume are based on EMQ FamiliesFirst's experience in delivering mental health
services in its existing Wraparound program. This budget assumes full staff and full census on day one and projects Medi-Cal revenue generation of $3,375,000
for the initial 12 month period. These revenue figures are based on a case management rate of $2.02 per minute, a mental health rate of $2.61 per minute, a
medication support rate of $4.82 per minute, a collateral rate of $2.61 per minute and a crisis intervention rate of $3.88 per minute. The blend of services is
anticipated to be 7% case management, 15% mental health, 1% crisis intervention, 1% medication support, 2% collateral, 10% ICC-case management, 64% IBHS-
rehab.
RFP 952-5322
< .·
Page: 18 of 27
Senate em 163 Wraparound and. Therapeuttc Foster care Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget· July 1, 2016 to June 30, 2017
ExhibitB
It is recognized that overhead cost is part of every organizations cost of doing business to evaluate direct service cost versus overhead
cost, please utilize this page to delineate what makes up your agencies overhead.
Below is an example of overhead cost components/categories, please feel free to adjust to best represent your agency
Cost Categories
Accounting/Finance
Human Resources
Information Tech.
Executive Management
Training
/Quality/Compliance
Total
Amount ReQuested
129,463
129,463
194,195
97 098
97,098
647,317
Explanation
Agency corporate
general accounting
and financial
services
Agency human
resources and
administration,
including recruiting,
training and
employee
development
Agency network,
communication,
security,
application
development and
maintenance
Agency
management and
leadership and
administration
Agency corporate
training, quality,
and compliance
requirements
1) Please provide your agency's total administrative overhead cost. $13,000,000
2) Please provide the percentage of your agency's total administrative overhead cost, as is it relates to your total agency cost. 15%
3) Please indicate your agency's proposed total cost for this service component. $4,500,000
4) Please indicate the percentage of your agency's administrative overhead cost charge, as it relates to the total cost proposed for this
service component. 15%
5) Please indicate the percentage of the total agency's administrative overhead cost, charged under this service component as it relates
to your agency's total administrative cost. 5%
RFP 952-5322 Page: 19 of 27 ExhibitB
··.s·;< \ . ·. Senate B111163 Wraparound and Therapeutic Foster care Services
FamiliesFirst, Inc. dba EMQ FamillesFirst
Budget. Jut, 1, 2017 to June 30, 2018
Budget Categories -Total Proposed Budget
Non Direct Consumer Cost Direct Consumer Cost
Mea1-1.;a1 Non Meai-1.;a1 Mea1-1.;a1 Non Mea1-1.;a1
Line Item Description (Must be itemized) FTE% Billable Cost Billable Cost Billable Cost Billable Cost Total
PERSONNEL SALARIES:
0001 Title Associate Director 1.00 $61.870 $20,623 $82,493
0002 Title Clinician I 4.00 $144,093 $48,031 $192,124
0003 Title Clinical Director 0.50 $34,147 $11,383 $45,530
0004 Title Community Development Spec (RCL) 1.00 $33,653 $33,653
0005 Title Addiction Prevention Counselor 3.00 $77,222 $25,741 $102,963
0006 Title EducationNocational Specialist 3.00 $77,076 $25,692 $102,768
0007 Title Clinical Program Manager 4.00 $191,145 $63,715 $254,860
0008 Title Facilitator 12.00 $350,118 $116,706 $466,824
0009 Title Family Partner {RCL) 4.00 $135,572 $135,572
0010 Title Family Specialist 22.00 $497,029 $165,677 $662,706
0011 Title Family Services Coordinator: Family Finding 1.00 $30,007 $10,003 $40,010
0012 Title Family Service Coordinator 1.00 $30,007 $10,003 $40,010
0013 Title Program Supervisor 3.00 $115,976 $38,659 $154,635
0014 Title Intake Coordinator 1.00 $29,087 $9,696 $38,783
0015 Title Administrative Assistant II 1.00 $24,914 $8,305 $33,219
0016 Title Billing Specialist 1.00 $23,268 $7,756 $31,024
0017 Title ED, Regional Executive Director 0.45 $39,089 $13,030 $52,119
0018 Title Health Information Management 1.00 $25,596 $8,532 $34,128
0019 Title Learning Partners 1.00 $52,034 $17,345 $69,379
0020 Title Outcomes & Evaluation 0.50 $17,400 $5,800 $23,200
0021 Title Quality Support 0.50 $28,721 $9,574 $38,295
SALARY TOTAL 65.95 $211,022 $70,342 $1,637,777 $715,154 $2,634,295
PAYROLL TAXES:
0030 OASDI old age survivor and disability $13,083 $4,361 $101,542 $44,339 $163,325
0031 FICA/MEDICARE $3,060 $1,020 $23,748 $10,370 $38,198
0032 U.1. $4,959 $1,653 $38,488 $16,806 $61,906
PAYROLL TAX TOTAL $21,102 $7,034 $163,778 $71,515 $263,429
EMPLOYEE BENEFITS:
0040 Retirement $8,441 $2,814 $65,511 $28,606 $105,372
0041 Workers Compensation $6,331 $2,110 $49,133 $21,455 $79,029
0042 Health Insurance (medical vision, life, dental} $23,351 $7,784 $181,235 $79,138 $291,508
EMPLOYEE BENEFITS TOTAL $38,123 $12,708 $295,879 $129,199 $475,909
SALARY & BENEFITS GRAND TOTAL $270,247 $90,084 $2,097,434 $915,868 $3,373,633
Mea1-c.;a1 Non Mea,-c.;a1
FACILITIES/EQUIPMENT EXPENSES: Billable Cost Billable Cost Total
1010 Rent/Lease Building 37,917 12,639 $50,556
1011 Rent/Lease Equipment 3,122 1,041 $4,163
1014 Maintenance (facility) 3,342 1,114 $4,456
1017 Other Depreciation 4,218 1,406 $5,624
FACILITY/EQUIPMENT TOTAL $48,599 $16,200 $64,799
OPERATING EXPENSES:
1060 Telephone $41,127 $13,709 $54,836
1062 Postage/Shipping/Printing 1,426 475 $1,901
1066 Office Supplies & Equipment 4,807 1,602 $6,409
1069 Program Supplies -Therapeutic 8,437 2,813 $11,250
1072 Staff Mileage/vehicle maintenance 165,487 55,163 $220,650
1074 Staff Training/Registration 5,011 1,671 $6,682
1076 Other· Emergency Flex Funds 63,000 $63,000
OPERATING EXPENSES TOTAL $226,295 $138.433 $ 364,728
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit 5,453 1,818 7,271
1082 Liability Insurance 17,382 3,030 $20,412
1083 Other -Administrative Overhead 485,488 161,829 647,317
FINANCIAL SERVICES TOTAL 508,323 166,677 $675,000
SPECIAL EXPENSES (Consultant/Etc.):
1089 Medication Supports I 16,380 I 5,460 $21.840
SPECIAL EXPENSES TOTAL 16,380 5,460 $21,840
TOTAL PROGRAM EXPENSES $4,500,000
RFP 952-5322 Page: 20 of 27 ExhibitB
.,., . Senate 8111163 Wraparound and Therapeutic Foster ea..-Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget· July 1, 2017 to June 30, 2018
voI1umts ot MeaI-c.;aI Non Mear-Cal
DIRECT SERVICE REVENUE: Svc Rate Billable Cost Billable Cost $Amt.
3000 Mental Health Services 94,515 $2.61 $246,684 $246,684
(Assessment, Plan of Care, lndividuaVFami/y/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage 203,298 $2.02 $410,662 $410,662
3200 Crisis Intervention 6,776 $3.88 $26,291 $26,291
3300 Medication Support 13,553 $4.82 $65,325 $65,325
3400 Collateral 27,105 $2.61 $70,744 $70,744
3500 Court Documentation, Report, Appearance $0
3600 Psychological evaluation $0
3700 ICC-Case Management 135,527 $2.02 $273,765 $273,765
3800 IHBS-Rehab 874,149 $2.61 $2,281,529 $2,281,529
3900 SB Non Billable Services 1,022,727 $1.10 $1,125,000 $1,125,000
DIRECT SERVICE REVENUE TOTAL 2,377,650 $ 3,375,000 $ 1,125,000 $4,500,000
OTHER REVENUE:
4000 Other $0
4100 Other $0
4200 Other $0
4300 Other $0
OTHER REVENUE TOTAL $0
TOTAL PROGRAM REVENUE $4,500,000
1,687,500 Medi-Cal Revenue 50% FFP
1,350,000 Medi-Cal Revenue 40% EPSDT (2011 Realignment)
337,500 Medi-Cal Revenue 10% County SB163 Trust Fund
$ 3,375,000 Total Medi-Cal Revenue
1,354,923 Total Medi-Cal Units
$ 2.49 Medi-Cal cost per unit
$1,125,000 Non Medi-Cal Billable Service Cost
1,022,727 Total Non-Medi-Cal BIiiabie units
$ 1.10 Non Medi-Cal cost per unit
Annualized Total Summary
$Dollar Amoun %Percernaae%
MeaI-c,;aI
Billable Cost $ 3,375,000 75%
Non MeaI-c.;aI
Billable Cost $ 1,125,000 25%
Total $ 4,500,000
RFP 952-5322 Page: 21 of 27 ExhibitB
'. s.nate Bill 163 Wraparound and Therapeutic F.oster Can1 Services
FamlllesFirst, Inc. dba EMQ FamiliesFirst
Budget• July 1, 2017 to June 30, 2018
PROPOSED BUDGET DETAIL NARRATIVE
BUDGET NARRATIVE
0001 Associate Director
I Total Amount
$ 82,493
1.0 FTE at a salary of $82,493 = $82,493
Master's degree (MA/MS). Must have appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of California.
Must meet the BBS requirements to provide clinical oversight and supervision with three to ten years of experience in healthcare/psychology/behavioral/mental
health. The Associate Director assists the clinical director with implementing strategies to accomplish the agency annual priorities at the program level. Directs
and develops managers, ensures CPMS are competent and have all tools necessary to lead teams.
0002 Clinician I
I Total Amount
$ 192,124
4.0 FTE at average salary of $48,031 = $192,124
Master's Degree (MA/MS) and at least two years of experience working with youth, young adults and families in a therapeutic environment is required. If
unlicensed must be a registered intern with the Board of Behavioral Sciences and receiving appropriate clinical supervision. Provides psychotherapy and
psychotherapeutic support to children and families.
0003 Clinical Director
I Total Amount
$ 45,530
0.5 FTE at a salary of $91,060 = $45,530
Master's Degree (MA/MS) in Psychology, Social Work, Marriage and Family Counseling or related field required. Must have appropriate license to practice as a
Licensed Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to provide clinical oversight and
supervision. Provides regional leadership and effectively manages, develops, maintains, monitors and ensures the clinical quality in multiple clinical programs.
0004 Community Development Specialist (RCL)
I Total Amount
$ 33,653
1.0 FTE at a salary of $33,653 $33,653
Bachelor's Degree {BA/ BS) in Marketing or related field preferred. The community development specialist develops resources that support the needs of young
people and families receiving agency services. Inspires and ensures community engagement in therapeutic and strength based opportunities to enhance or
create mental health programs.
0005 Addiction Prevention Counselor
I Total Amount
$ 102,963
3.0 FTE at an average salary of $34,321 = $102,963
Bachelor's degree (BA/ BS) or higher in Psychology, Counseling or Social Work; certified drug and alcohol counselor is preferred. Two to four years related
experience or an equivalent combination of education and experience working with youth or young adults with co-occurring disorders.
0006 Education/Vocational Specialist
I Total Amount
$ 102,768
3.0 FTE at an average salary of $34,256 $102,768
Associate's Degree {AA/ AS) AND six (6) years related experience in a mental
health/education/vocational setting required.
• OR Bachelor's Degree (BA/BS) AND four (4) years related experience in a mental
health/education/vocational setting required.
• OR Master's Degree (MA/ MS) in a mental health related field AND two (2) years related experience in a mental health setting required.
RFP 952-5322 Page: 22 of 27 Exhibit B
Senate BIR 163 Wraparound and Therapeutic Foster Ce1'9 Services
FamiliesFirst, Inc. dba EMQ FamiliesFirst ,, •. Budget-July 1, 2017 to June 30, 2018
0007 Clinical Program Manager
I Total Amount
$ 254,860
4.0 FTE at an average salary of $63,715 = $254,860
Master's degree (MA/MS) required in a related field; two to four years related experience. Must have appropriate license to practice as a Licensed Clinical
Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to provide clinical oversight and supervision. Hires,
develops, trains, manages and retains clinical program staff.
0008 Facilitator
I Total Amount
$ 466,824
12.0 FTE at an average salary of $38,902 = $466,824
Master's Degree (MS/ MA) in Psychology, Social Work, Counseling or related field required. Works in the family's home and a variety of community and/or
treatment settings, coordinates services with an understanding of the complexity of each family while blending the clinical care of the youth with the facilitation
of the life domain planning process.
0009 Family Partner (RCL)
I Total Amount
$ 135,572
4.0 FTE at an average salary of $33,893 = $135,572
High School Diploma or General Education Development (GED) required; some college education is preferred. Three years of experience as a parent or caregiver
of child with special needs. Implements family friendly practices by providing a parent's perspective to the routine operations and developments of programs.
0010 Family Specialist
I Total Amount
$ 662,706
22.0 FTE at an average salary of $30,123 = $662,706
Bachelor's degree (BA/BS) required; six months, one year, or two years of experience working with SEO children required, dependent upon connect, OR
equivalent combination of education and experience. Develops a strength based relationship with youth and caregivers in order to intervene with maladaptive
behaviors while developing the youths strengths and interests.
0011 Family Service Coordinator: Family Finding
I Total Amount
$ 40,010
1.0 FTE at a salary of $40,010 = $40,010
Associate's degree (AA/AS) and six years of experience or Bachelor's degree (BA/BS) with four years of experience or Master's degree (MA/MS) with two years
of experience in related field is required. Works independently in family homes and a variety of community and/or treatment settings directly with children and
adults. Is responsible for developing and coordinating family-centered teams.
0012 Family Services Coordinator
I Total Amount
$ 40,010
1.0 FTE at an average salary of $40,010 = $40,010
Associate's degree (AA/AS) and six years of experience or Bachelor's degree (BA/BS) with four years of experience or Master's degree (MA/MS) with two years
of experience in related field is required. Works independently in family homes and a variety of community and/or treatment settings directly with children and
adults. Is responsible for developing and coordinating family-centered teams.
0013 Program Supervisor
I Total Amount
$ 154,635
3.0 FTE at an average salary of $51,545 = $154,635
Bachelor's Degree (BA/ BS) in Psychology, Social Work, Counseling, Education or related field. Minimum of three (3) years of experience in social or mental
health services delivery, residential care supervision or education required. Hires, develops, trains and manages program staff. Coordinates and supervises daily
program operations.
0014 Intake Coordinator
I Total Amount
$ 38,783
1.0 FTE ata salary of $38,783 = $38,783
Bachelor's degree (BA) in social work, psychology, marriage, child and family counseling, counseling psychology; minimum of two years of experience working
with dependent children is required. This position is responsible for placement of clients into the program.
RFP 952-5322 Page: 23 of 27 Exhibits
I • ',·''.·· Senate BUI 163 Wraparound and Therapeutic Foster Care Services
FamlliesFirst, Inc. dba EMQ FamiliesFirst
'' :,,,~ ,,.•; . ;..;,. :'. ,.;, ., ... ,,/ .· ',; Budaet-July 1, 201.1 to June 30, 2018
0015 Administrative Assistant II
I Total Amount
$ 33,219
1.0 FTE at a salary of $33,219 = $33,219
High school diploma, GED or equivalent combination of education and experience required. The administrative assistant II provides administrative support to
program staff; performs private insurance billing and handles all flex funds for the Wrap program.
0016 Billing Specialist
I Total Amount
$ 31,024
1.0 FTE at an average salary of $31,024 = $31,024
High school diploma, GED or equivalent combination of education and experience required. This position inputs the EPSDT billing into Avatar along with
reconciliation and preparation of claim certification and inputs the units and flex funds on SB163 invoice.
0017 ED, Regional Executive Director
I Total Amount
$ 52,119
0.45 FTE at a salary of $115,818 = $52,119
Master's Degree (MA/MS) in Psychology, Social Work, Marriage and Family Counseling, Administration, Business or related field is required. Must have
appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet the BBS requirements to
provide clinical oversight and supervision. This position provides leadership, strategic direction and operational oversight. This position provides leadership,
strategic direction and operational oversight.
0018 Health Information Management
I Total Amount
$ 34,128
1.0 FTE at a salary of $34,128 = $34,128
Associates degree (AA/AS) required with one year direct work experience. Database, Visual Basic, and/or Crystal Reports experience required. Basic knowledge
of legal issues regarding releases of information and other medical records issues required. Technical training on report writing in a database environment
required.
0019 Learning Partners
I Total Amount
$ 69,379
1.0 FTE at an average salary of $69,379 = $69,379
Bachelor's Degree (BA/BS) or equivalent experience in related field required. Two years of experience in education/learning/training. Assesses learning needs,
designs, develops and presents leaninR. activities.
0020 Outcomes Evaluation
I Total Amount
$ 23,200
0.5 FTE at a salary of $46,400 "' $23,200
Bachelor's degree (BA/BS) required with six years research experience with statistical analysis software, database development, management, merging of
multiple databases. Four (4) years of related experience in literature review, program research, data collection, intermediate-advanced evaluation, and
advanced knowledge and usage of statistical software package. Minimum of one (1) year experience in training research activities and lead responsibilities in
research projects.
0021 Quality Support
I Total Amount
$ 38,295
0.5 FTE at a salary of $76,589"' $38,295
Master's Degree (MA/ MS) in Psychology, Social Work, Marriage and Family
Counseling or related field required. Must have appropriate license to practice as a Licensed Clinical Social Worker or Marriage Family Therapist in the State of
California. Must meet the BBS requirements to provide clinical oversight and supervision. Develops, maintains, and manages operational infrastructure
functions that provide support to service delivery (intake, medical records), the assurance of quality (utilization review and quality and manages operational
infrastructure functions that provide support to service delivery (intake, medical records), the assurance of quality (utilization review and quality assurance
structures, training structures, outcomes evaluation structures, risk management oversight) for a distinct geographic region in compliance with agency
standards.
0030OASDI
I Total Amount
$ 163,325
Calculated at 6.2% of salaries.
I Total Amount
RFP 952-5322 Page: 24 of 27 Exhibit B
' ,'.' · .. ,; .. ·. Senate 8111163 Wraparound and Therapeutic FQSter Care Services
t·-·;.it;;/·'
FamiliesFirst, Inc. dba EMQ FamiliesFirst
Budget-Jul)' 1, 2017 to June 30, 2018
0031 FICA/MEDICARE I$ 38,198
Calculated at 1.45% of salaries.
0032 UI
I Total Amount
$ 61,906
Calculated at 2.35% of salaries.
0040 Retirement
I Total Amount
$ 105,372
Calculated at 4.0% of salaries.
0041 Workers Compensation
I Total Amount
$ 79,029
Calculated at 3.0% of salaries.
0042 Health insurance (medical, vision, life, dental)
I Total Amount
$ 291,508
Calculated at aooroximatelv 11% of salaries.
1010 Rent/Lease Building
I Total Amount
$ 50,556
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes building, storage and file storage unit rental payments and all the costs associated with storing and retrieving of
client, personnel or other files or records.
1011 Rent/Lease Equipment
I Total Amount
$ 4,163
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes rental payments for equipment including leased copiers, faxes, postage machines, phone systems, laptops or
other communication, office or facility equipment.
1014 Maintenance (facility)
I Total Amount
$ 4,456
All occupancy costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends and the utilization of the
agency's existing office in Fresno. This includes common area maintenance on leased building charges, maintenance/building repair charges, HVAC
maintenance and repair, landscaping, janitorial services, confidential paper shredding services, in-house or outside equipment repair and labor.
1017 Other-Depreciation
I Total Amount
$ 5,624
Depreciation includes deprecation on leasehold improvements, office furniture/fixtures and equipment meeting amortization thresholds. Costs are allocated
between programs on the basis of payroll dollars and have been estimated based on historical trends.
1060 Telephone
I Total Amount
$ 54,836
Cell phones, Land Lines, DSL, fax charges, phone system; also wireless cards for laptop computers enabling us to maintain a fully functional mobile work force to
deliver in-home services. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
RFP 952-5322 Page: 25 of 27 Exhibit B
'..':',· .. · ... ''.{··::. · •. ,.· .. • ... Senate BJll 163 Wraparound and Therapeutic Foster Care Services
FamillesFlrst, Inc. dba EMQ FamlliesFirst
Budget· July 1, 2017 to June 30, 2018
1062 Postage/Shipping/Printing
I Total Amount
$ 1,901
Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of payroll dollars and have been estimated based on historical trends.
1066 Office Supplies & Equipment
I Total Amount
$ 6,409
Office supplies and equipment include, but are not limited to: paper, pens, files, staplers, break rooms supplies such as coffee, paper cups, plastic utensils are
also included. Costs are allocated between programs on the basis of direct labor dollars and have been estimated based on historical trends.
1069 Program Supplies-Therapeutic
I Total Amount
$ 11,250
Includes those supplies utilized in the direct delivery of therapeutic services to clients. Cost is estimated to be approximately $15.00 per direct care staff per
month. Materials, cash payments, outing costs, etc. used to motivate or reinforce desired behavior.
1072 Staff Mileage/vehicle maintenance
I Total Amount
$ 220,650
Primarily includes mileage reimbursement paid (at the current federal rate to staff supporting program or program related activities. In addition, a component
of travel costs may include overnight travel by staff for training, meetings or conferences. This figure also takes into consideration that we anticipate that the
majority of all program services will be delivered in the community. Also includes the transportation of clients. Costs are estimated to be approximately 9.38%
of direct personnel costs prior to taxes and benefits.
1074 Staff Training/ Registration
I Total Amount
$ 6,682
Includes ongoing training in the Wraparound model of care, organizational tools, team/organizational psychology, philosophy of client based services,
integration of roles/team dynamics, assessment and individualized treatment planning, general services, organized admissions, and individualized treatment
planning associated with the Wraparound system of care. Also includes other mandatory trainings such as first aid and CPR.
1076 Other -Emergency Flex Funds
I Total Amount
$ 63,000
Cost of "whatever it takes" flexible funding for client needs to maintain growth, functioning and recovery. Flexible funds were budgeted at $35 per client per
month. Requests above $300 are approved by the Wraparound Community Team.
1081 External Audit
I Total Amount
$ 7,271
Includes annual audit insuring all financial records are relevant and accurate and in compliance with state and federal laws and regulations. Audit costs are
allocated between programs on the basis of payroll dollars and have been estimated based on historical costs.
1082 Liability Insurance
I Total Amount
$ 20,412
Includes general business liability and property coverage along with professional liability insurance.
RFP 952-5322 Page: 26 of 27 ExhibitB
,.'·,, if, · .. ', ·:,, ,·, .· ... ,· ' Setlate BIH 163 Wraparound and Therapeutic Foster CaNI Services
FamiliesFirst, Inc. dba EMQ FamillesFirst
1, Budget-July 1, 2017 to June 30, 2018
1083 Other-Administrative Overhead
I Total Amount
$ 647,317
Represents the indirect costs of the agency's general and administrative shared support services such as finance, accounting, billing, human resources, clinical
administration, information technology, quality assurance and outcomes/evaluation, insurance, professional fees, HIPAA compliance and clinical record audits,
quality management oversight of Medi-Cal records, risk management and program fidelity, recruiting and human resources support, MIS infrastructure & QI/UM
department support and oversight as well as executive management. Costs that cannot be specifically charged to a program are allocated to programs on the
basis of direct labor program costs prior to the addition of taxes and benefits. Indirect costs have been budgeted at 15% of program costs.
1089 Medication Supports
I Total Amount
$ 21,840
This is a contract position estimated at to cost $175 per hour. The psychiatrist will be required to provide 2.61 hours per week, or approximately 10.44 hours
per month ($1,820 per month x 12 months= $21,840) and will provide medical oversight/supervision of program services.
3000-3900 Medi-Cal Revenues I Total Amount
$ 4,500,000
Medi-Cal eligibility is estimated to be 90% of all clients served. For the purpose of a conservative revenue projection, only the clinicians, facilitators and family
specialists were assumed to be billable positions. Blend of service and unit volume are based on EMQ FamiliesFirst's experience in delivering mental health
services in its existing Wraparound program. This budget assumes full staff and full census on day one and projects Medi-Cal revenue generation of $3,375,000
for the initial 12 month period. These revenue figures are based on a case management rate of $2.02 per minute, a mental health rate of $2.61 per minute, a
medication support rate of $4.82 per minute, a collateral rate of $2.61 per minute and a crisis intervention rate of $3.88 per minute. The blend of services is
anticipated to be 7% case management, 15% mental health, 1% crisis intervention, 1% medication support, 2% collateral, 10% ICC-case management, 64% IBHS-
rehab.
RFP 952-5322 Page: 27 of 27
" .. '.i .• SelMttlt BIi 163 Wraparound and TINN'a,-utle Foeler Care 8erYlcee
FamillesFirst, Inc. dba EMQ FamlllesFirst
Budget-July 1, 2017 to June 30, 2018
ExhibitB
.. •.
It is recognized that overhead cost is part of every organizations cost of doing business to evaluate direct service cost versus overhead
cost, please utilize this page to delineate what makes up your agencies overhead.
Below is an example of overhead cost components/categories, please feel free to adjust to best represent your agency
Cost Categories
Accountina/Finance
Human Resources
Information Tech.
Executive Manaaement
Training
/Quality/Compliance
Total
Amount Reauested
129 463
129,463
194,195
97,098
97,098
647,317
Exolanation
Agency corporate
general accounting
and financial
services
Agency human
resources and
administration,
including recruiting,
training and
employee
development
Agency network,
communication,
security,
application
development and
maintenance
Agency
management and
leadership and
administration
Agency corporate
training, quality,
and compliance
requirements
1) Please provide your agency's total administrative overhead cost. $13,000,000
2) Please provide the percentage of your agency's total administrative overhead cost, as is it relates to your total agency cost. 15%
3) Please indicate your agency's proposed total cost for this service component. $4,500,000
4) Please indicate the percentage of your agency's administrative overhead cost charge, as it relates to the total cost proposed for this
service component. 15%
5) Please indicate the percentage of the total agency's administrative overhead cost, charged under this service component as it relates
to your agency's total administrative cost. 5%
RFP 952-5322
Contract I ______ _
Contract Tenn ______ _
Annual Contract Max -------Maximum Contract sum ______ _
Total BIiied to date ______ _
%Billed -------
D88Cllat
11M
1234567
1234567
·-mm
Smith, Joe 01/01/15
Smith Joe 01/01/15
AAP Count __ --'-1
PRO Count __ -'-1
TFC Count ___ o~
Total Kids Count 2 ----
Average Cost/Child :
Enron.cl RCL
Dalt
01/01/15
01/01/15
.. o. Star current
3 13 13
3 13 13
Total Non-MC Units
Total Medi-C al Units
Grand total Units
Prepa re d by: Date: __________ _
(EMQ)
Aid
~
07
40
Page 1 of 4 Ex hibit C
Contractor Name ----------------Address _______________ _
Invoice End Date _______ 31 ___ 31-'-/_20.;..1_6 ______ _
Reporting Month _______________ _
-Non-Medi-Cal ~-,.. Tofll . .... TF ,. nt Uftlll Amount ,...
X 10 $ 100 .00 10 $ 100.00 $ 25 .00 20 $ 225.00
X 10 $ 100.00 10 $ 100 .00 $ 25 .00 20 $ 225 .00
AAP Non-MC Dollars ____ """$.__ ____ 1"""0.;.o:.;:.o~o
Non-AAP Non-MC Dollars ____ ....;$,:_ __ 1:..::0:.::0.:.::.0~0
20
20
40
Total Non-MC Dollars ____ ..;$'-----=2:.::0.::.0:.::.0.::....0 T::~~::d~-~~ g~:::~-----!,:_---=2:a:~:.::~.:.:::~c::-~
Grand Total Dollars------'$,-----4-=50.::..:.::0.::....0
Approved by: __________ _
Date: -----('!"'DS'!l'S!"') ___ _
RFP 952-5322 Page 2 of4 Exhibit C
Contrac:t# Contractor Name
Contract Tenn __________ _
Report Begin Date _________ _
Annual Contract Max -----------Report End Date _________ _ Ann u a I Medi-Cal Total Units ---------------------Total Billed to date To ta I Dollars ---------------------% BIiied -----------
12/5/2014 ICC-Intensive Care Coordination-Katie A 100.00 $193.00 Open
1216/2014 ICC-Intensive Care Coordination-Katie A 100.00 l$193.00 Open
1217/2014 ICC-Intensive Care Coordination-Katie A 100.00 $193.00 Open
12/8/2014 ICC-Intensive Care Coordination-Katie A 100.00 $193.00 Open
12/9/2014 ICC-Intensive Care Coordination-Katie A 100.00 $193.00 Open
-----------------
RFP 952-5322
Contract# _________ _
Contract Term Annual Contract lllax __________ _
Annual Nonlhdl-Cal
Total Billed to datll-----------
12/5/2014
12/6/2014
1217/2014
12/812014
12/912014
% BIUad _________ _ -• -
Page 3of4
Contractor Name __________ _
Report Begin Date _________ _
Report End Date Total Units __________ _
Total Dollars __________ _
ICC-Intensive Care Coordination-Katie A
ICC-Intensive Care Coordination-Katie A
ICC-Intensive Care Coordination-Katie A
ICC-Intensive Care Coordination-Katie A
ICC-Intensive Care Coordination-Katie A
Exhibit C
RFP 952-5322
Contract# Contract Term __________ _
Annual Contract Mix __________ _
T~~~~:1:~e:oF:a:----------------------%Billed -----------
!Service Datllf DSS case ID piQ Flex Fund ID Codj c4§ PIG Pdi4i?erinltlon !
12/5/2014 1234567 505A Phone
12/6/2014 1234567 202 Sports equipment
Page 4 of 4 Exhibit C
Contractor Name Report Begin Date __________ _
Report End Date Total Units __________ _
Total Dollars -----------
CMTa, .... _,,.,.,.11 pfg ii, \.
' ' ' I !I ili'1ffliiijif .,
Phone approved for ...... .
Approval for Soccer Cleats and Shin gaurds because .....
$40 .00
$20.00
RFP 952-5322 Page : 1 of4 Exh ibit D
Cost Allocation and Connet Budget Comparison
July 2015 -June 2016 Contract Year 0% 0% 0% 0% 0% c..a Budaet % Q1 (Jul..-Q21oct.OKI QSfJa-Q4f4n,.Jgft) YTD FYJ01S.1$ 'It -$ 2 634 295 58.54% $ -$ -$ -$ -$ -#DIV/0!
Plllaltaxe& $ 263 429 5.85% $ -$ -$ -$ -$ -#DIV/0!
=--:-!'.-Benefits $ 475 909 10 .58% $ -$ -$ -$ -$ -#DN/0!
Bulklng $ 50556 1.12% $ -$ $ $ $ #DIV/0! ----..._._. -Equipment $ 4163 0.09% $ -$ -$ -$ -$ -#DIV/01
(Facillly) $ 4 456 0.10% $ -$ -$ -$ -$ -#DIV/0!
~-Depnlciltlon $ 5624 0 .12% $ -$ -$ -$ -$ -#DIV/0!
$ 54 836 1.22% $ -$ -$ -$ -$ -#DIV/0!
$ 1 901 0.04% $ -$ -$ -$ -$ #DIV/0! -
Ollca SUpplies Ind Equi°pment $ 6409 0 .14% $ -$ -$ -$ -$ -#DIV/0!
~Supplies-~lie $ 11 250 0.25% $ -$ -$ -$ -$ -#DIV/0!
$ 220 650 4.90% $ $ _ mamtenance --$ -$ -$ -#DN/0!
_. •-Reglslndlon $ 6 682 0.15% $ -$ -$ -$ -$ -#DIV/0!
~-Emargency Flex Funds $ 63000 1.40% $ -$ -$ -$ -$ -#DIV/0!
&cllilll!Audil $ 7 271 0.16% $ -$ -$ -$ -$ -#DIV/0 !
U-,lnsuranc8 $ 20 412 0 .45% $ -$ -$ -$ -$ -#DIV/0!
a..,. Adminilllrative OVemead $ 647 317 14 .38% $ -$ -$ -$ -$ -#DIV/0!
Supports $ 21 840 0.49% $ -$ -$ -$ -$ -#DIV/0! -$ 4,500,000.00 $ -$ -$ -$ -$ -
Q1 Q2 Q3 Q4 T YTD '~-~-=-::•·.----.J-
D .,..,_ -•
~ ~ ;:-. --. -----
~~~~i1l'mlrm'DIII _..c::.· --~--;. .,, -. . ----•. ;
:Si. ~~ ' ----·· ~---.. --~
PBQS,RAM EXPENSE_S 1150_CUents)
90% 10% 95% 5%
Medi-Cal Billable Cost Non Medi-Cal Billable Cost
Total Non-AAP AAP Non-AAP AAP
$ 2,834,295 $ 1,848,803 $ 785,492 $ $
$263,429 $184,880 $78,549 $166,965 $4,218
EMPLOYEE BENEFITS TOTAL $475,909 $334,003 $141,906 $301,640 $32,365 $134,285 $7,619
SALARY & BENEFITS GRANO TOTA $3 ,373,633 $2 ,387,888 $1 ,005,947 $2,138,258 $229,429 $951,9211 $54,017
Rent/I.ease Building $50,556 $ 37,917 $ 12,639 $ 34,243 $ 3 ,674 $ 11 ,960 $ 679
Rent/I.ease Equipment $4,163 $ 3,122 $ 1,041 $ 2,619 $ 303 $ 985 $ 56
Maintenance (facility) $4 ,456 $ 3,342 $ 1,114 $ 3,018 $ 324 $ 1,054 $ 60
Other -Depreciation $5,624 $ 4,218 $ 1,406 $ 3,809 $ 409 $ 1,330 $ 76
FACILITY/EQUIPMENT TOTAL $64,799 $48,599 $16 ,200 $43,889 $4,710 $15,329 $871
Telephone $54,836 $ 41 ,127 $ 13,709 $ 37 ,142 $ 3,985 $ 12,973 $ 736
Postage/Shipping/Printing $1,901 $ 1,426 $ 475 $ 1,288 $ 138 $ 449 $ 26
Office Supplies & Equipment $6,409 $ 4,807 $ 1,602 $ 4,341 $ 466 $ 1,516 $ 86
Program Supplies -Therapeutic $11,250 $ 8,437 $ 2,812 $ 7,619 $ 818 $ 2,661 $ 151
Staff Mileage/vehicle maintenance $220,650 $ 165,488 $ 55,163 $ 149,452 $ 16,036 $ 52,201 $ 2,962
Staff Training/Registration $6 ,682 $ 5,011 $ 1,671 $ 4,525 $ 486 $ 1,581 $ 90
Other -Emergency Flex Funds $63 ,000 $ 63,000 $ $ $ 59,617 $ 3,383
OPERATING EXPENSES TOTAL $364,728 $ 226,296 $ 138,432 $ 204,367 $ 21,929 $ 130,998 $ 7,434 s.:
External Audit $7,271 $ 5,453 $
Liability Insurance $20,412 $ 17,382 $
Other -Administrative Overhead $647 ,317 $ 485,488 $
FINANCIAL SERVICES TOTAL $675,000 $ 508,323 $
};
Medication Supports $21,840 $ 16 ,380 $
SPECIAL EXPENSES TOTAL $21,840 $ 16,380 $
$1 ,126,367 $799,598
$UOOOOO
RFP 952-5322 Pago: 2 .,, -D --.................. 0, I Q4 2,834,295.00 293,429.00 475,909.00 50,556.00 4,163.00 4,456.00 5,624.00 54,836.00 1,801.00 6,409.00 11,250.00 220,650.00 6,MZ.00 $3,000.00 7,271.00 20,412.00 647,317.00 21,840.00 , .... 1 I I I I I Jul-11 Au9-11 ..... 11 Q1 Oct,11 Q2 Jon.ti _,. _,. 0, ....... 11___] Q4 L YTD 2,412,968.00 241,296.00 435,925.00 46,203.00 3,1104.00 4,072.00 5,139.00 50,115.00 1,737.00 5,1167.00 10,281.00 201,652.00 1,106.00 59,617.00 8,1145.00 19,565.00 591,593.00 19,980.00 111 .... .... .... .... ·-.. ... ... OM ·-.... . .. ... ·-·-·-B•,clgol I ,M,11 I ~11 I ..,.,. I Q1 I -~· I __ ,. I Doc-ti I Q1 I .,_,. I -.11 I -11 I ~ ~~I Aer:11 I 111ay-11_ .I "-11 I Q4 I YTD 221,329.00 22,133.00 38,994.00 4,353.00 359.00 364.00 485.00 ,.n1.oo 164.00 552.00 969.00 19,9811.00 576.00 3,383.00 626.00 1,&17.00 55,734.00 1,8'0.00 :.I ~l .:.I .:.I ~~.:..J .:..1 .:.I .:..1 .:.I .:..I ~ ••L ....
RFP 952-5322 Page: 3of4 ExhibllO c:o.t---ctlludgll~rllon Jul.11 ti Q1 Oct-11 -11 DM-11 Q2 Jan-11 Fff-11 --11 QI 11 I -.11 CM YTil 4,925 15,898 438,444 14,793 2,1M .... 0.00 0.00 D.00 0.00 I.OD 0.11 0,00 0.00 0.00 0,00 0.00 uo ,.oo .... 0.00 OM 0.00 IWCII-A# Budg,t M-15 Aoo,1S -..1s Q1 -1$ ..... 1$ Doo-15 Q2 ...... ,.11 lillr-11 QJ ..-11 ...,.1, .... Q4 YTO i-179,149.00 p,,i,,i-17,915.00 ~-32,365.00 ~ .... 3,674.00 ~ ....... :m.oo ~,...,_, 324.00 ---~ 409.00 . r...,... 3,985.00 138.00 Olba..,...11111~ 466.00 ............ '-818.00 . 111111......,..._ 16,036.00 . SIii_,_.._ 486.00 . . iot-----Alr---~-528.00 ,.....,_ 1,6&1.00 Iota----47,044.00 ~~ 1,587.00 -Toll!,.,_ -.,t!M ... ... ... ... IM ... ... ... I.IO ... ... ... ... ... ... ... .
RFP 952-5322 Page: 4 014 ExhibltD coot Allocatlon and COnlnlct Budget c-partaon ., .. w"' tliJ • o1une ~• 1,ornrac:1 TNr -,r_ Budaat Jul.11 ·-,, -,, Q1 Ocl-11 __ ,, Dec-11 Q2 .,.,..,, .,..,.,. ... ,., . Q3 __ ,. ~, Jun-11 Q,t YTD -743,313 . . ,... .... 74,331 . . . ~Benella 134,285 . . ,_ -llullding 11,1180 . -. Equlpmenl 986 -. (FIIClly) 1,054 . -. . OIMlr-~ 1,330 . . . . . TlllphOM 12,973 . . . Oftlce SuppllN Md --449 . . . . 1,518 -. . ~ SuppllN. Tlletapa1*': 2,881 . -. Mle1g1Yllllcfl-52,201 -. . -T-~ 1,581 . -Olher-Ernergenq, Flox.FunOa 59,817 . . . . ~-1,720 -. . . . I.Jabll1 lnaura,ce 2,8157 . Olller. ---Ovl"1ead 153,139 -. -. . ~Slipporla 5,187 . . . . T-·-1,211,148.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.08 0.00 0.00 0.00 0.00 0.00 o.oo 0.08 0.00 --Coot Budgot Jul.IS Aut-ff Stp-11 Q1 Oct-15 Now-15 Olo-15 Q2 ..... 1$ Fef>.IS .... Q3 Apr-11 lllay-lS --Q4 YTD IS*too 42,180.00 . p.,a-4,218.00 . ~-7,619.00 . . . ~ ... 679.00 . . . ~~ 56.00 . ---(Fdy) 60.00 . . 101--~ 711.00 . . . ir...-736.00 . . 26.00 . """~-~ 86.00 . . . . "'-8!Wlal·l1->uo 151.00 . . . -~-2.962.00 . SWT_._..., 90.00 . . . . lotw-~Flok-3,383.00 ~-98.00 . ~-163.00 . . IOI-·-°""'-8,890.00 . . .,._,~ 293.00 . . . . . . ... ~ 71--.. I.II .... .... .... .... . ... .... . ... .. . .. ,,. .... .... ... ... ..
Exhibit E
Page 1 of 3
FRESNO COUNTY MENTAL HEAL TH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, each contractor, contractor's employee and subcontractor
must sign the Contractor Acknowledgment and Agreement form and return this form to the
Compliance officer or designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing for
mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County's Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit E
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit E
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _______________ _
Discipline: 0 Psychiatrist O Psychologist O LCSW O LMFT
Signature: ______________ Date: _/ __ /_
For Group or Organizational Providers
Group/Org. Name (print): ________________ _
Employee Name (print): ________________ _
Discipline: 0 Psychiatrist O Psychologist O LCSW O LMFT
0 Other: ________________ _
Job Title (if different from Discipline): ___________ _
Signature: ______________ Date: __ /_/ __
Documentation Standards For Client Records
Exhibit F
Page 1 of 3
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the
record have a specific document or section addressing these topics.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client
record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
• Presenting problems and relevant conditions affecting the client's physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
• Documentation will describe client's strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete
developmental history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as
well as illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A five axis diagnosis from the most current DSM, or a diagnosis from the most current
ICD, will be documented, consistent with the presenting problems, history mental status
evaluation and/or other assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document
changes in the client's condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B. Client Plans
1. Client plans will:
• have specific observable and/or specific quantifiable goals
Exhibit F
Page 2 of 3
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
• the person providing the service(s), or
• a person representing a team or program providing services, or
• a person representing the MHP providing services
• when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
• a physician
• a licensed/ "waivered" psychologist
• a licensed/ "associate" social worker
• a licensed/ registered/marriage and family therapist or
• a registered nurse
• In addition,
• client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client's
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to, reference to the client's participation and agreement in the
body of the plan, client signature on the plan, or a description of the client's
participation and agreement in progress notes.
• client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
• when the client's signature is required on the client plan and the client refuses or is
unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client's progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person's professional degree, licensure or job title;
and the relevant identification number, if applicable
• 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:
Exhibit F
Page 3 of 3
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
OUTCOME MEASUREMENTS
Evaluation Outcomes
Element
Cost Cost Neutrality
Effectiveness
Family Measurable
Functioning improvement in
individual and family
functioning status
Prevention of Maintain target pop.
Placements in children with complex
More Restrictive needs (RCL 10-14)
Environments in family like settings
Improvement of Measurable
Emotional and improvement in
Behavioral functioning status
Adjustment
School Increased school
Attendance attendance of children
in the target
population Enrollment
in the least restrictive
environment
Academic Increased student
Performance performance,
particularly in reading,
math and spelling
Parent/Caregiver High level of
Satisfaction satisfaction with the
services provided
through the
Wraparound Process
Improvement in Increased level of
Family parenUchild/sibling
Involvement involvement
Family & Child High level of goal
Goal Attainment attainment
Indicators
NO additional funding
requested/required
Improved scores on clinical
assessment tools
WRAP Partici12ants:
-Reduce incidence of
Placement in RCL 10-14
group homes for those in
Program
-Placement in a stable, family-
like setting
-Move to lower level family-like
setting
Improved scores on clinical
assessment tools
Increase in # of days child
attends school. Decrease in the
level of restrictiveness in the
school environment.
-Improvement on standardized
tests
-Improvement on daily class
assignments
-Class Level Advancement
High satisfaction scores on the
following instruments:
-CSQ-8
-CSQ-18/EMQ
-YSQ
Observing increased involvement
Narratives re: increased
involvement
Scores on clinical scales
High level of goal attainment
reported on Self-Report
Questionnaire
-
Exhibit G
Page 1 of 1
Data
Sources
/Measuring
Tool
RFP952--53Z2
ORGANIZATION :
Page : 1 of2
ACTIVITY REPORT
FamiliesFinst, Inc. dba EMQ FamilieaFinst (RFP 952-5322)
SERVICES:
CONTRACT PERIOD:
Senate B111163 (SB163) Wraparound and Therapeutic Foster Care ServlcM
July 1 20XX to June 30, 20XX
GENERAL OUTCOME GOAL: Children and their long term supports will receive services to help them
build on their strengths, to prevent group home placement, step down
from group home level of care 10 or higher, and/or maintain current living
arrangements.
a. AAP
b. Probation
c. Child WeWare
the
a. Counselingmierapy provided by SB 163 Provider staff
b. Counseling/Therapy provided by Star, MHS or CPI
c. Counseli ovided b Count Mental Health Staff
a. Goal Achievement
b. Dependency dismissed at youth's request {of age)
c. Reunification was successful and dependency was dismissed
d. Returned to out of home care (higher level of care)
e. Subsequent removal due to abuse
f. In JJC eu&tody/youth rearrested
g. Dissatisfied with sarvices/voluntarily disanrolled
h. Family declined intensive service
i. Services no longer needed to meet educational needs {IEP)
j. Moved out of area
Jul
0
0
0
0
0
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0
0
0
0
0
0
0
0
0
0
0
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0
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0 0
0 0
0 0
0 0
0 0
k. AWOURan awa~======.,,------------------------+--::--+-~-+--:--+--:~-,... ..... ~. --0 0 0
0 0
a. Clients enrolled for O • 3 months 0 0 0
b. Clients enrolled for 3 -6 months 0 0 0
c. Clients enrolled for 6 -12 months 0 0 0
d. Clients enrolled for 12-18 months 0 0 0
e. Clients enrolled for 18+ months 0 0 0
Katie A Mandates
a. Number of Clients who received an ICC Meeting 0 0 0
b. Number of Clients whO received an IHBS Service 0 0 0
c. Number of Teami Meetin s attended with CWS 0 0 0
CLIENT DEMOGRAPHICS For current month
a. Total number of Hispanic or Latino clients 0 0 0 0
b. Total number of White clients 0 0 0 0
c. Total number of Black or African American 0 0 0 0
d. Total number of Asian clients 0 0 0 0
e. Total number clients of an ethnicity not defined by the above categories 0 0 0 0
f. Total number female clients 0 0 0 0
g. Total number male clients 0 0 0 0
h. Total number of clients residing with parenV relative 0 0 0 0
i. Total number of clients residin with foster care avider 0 0 0
COMMENTS: PLEASE PLACE ANY COMMENTS OR NOTES IN THE NOTES TAB. THANK YOU
Exl'ibitH
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0 0
0 0 0 0
0 0 0 0
0
0 0 0 0
0 0 0
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0 0 0 0
0 0 0 0
0 0 0
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0 0 0
0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0
0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0
0 0 0 0
0 0 0 0
0 0 0
RFP 952-5322 Page: 2of2
ORGANLZA TION:
ACTIVITY REPORT
FamillesFirst, Inc. dba EMQ FamillesFirst {RFP 952-5322)
SERVICES:
CONTRACT PERIOD:
Senate B 111163 (SB163) Wraparound and Therapeutic Foster Cara Se
July 1 20XX to June 30, 20XX
GENERAL OUTCOME GOAL: Children and their long term supports will receive services to help them
build on their strengths, to prevent group home placement, step down
from group home level of care 10 or higher, and/or maintain current living
arrangements.
SB163 SERVICES CLIENT INFORMATION :
I_ ,er-month
a.AAP
b. Probation
c. Child WeWare
d. Matrix
:r. I ........ ANill"lll6ft ..... IHP(: aNVnVSII referred hv:
a.AAP
b. Probation
c. Child We~are
:t.. lft""_, .. ftl of 11,a monlh and receiYed IWVioea while in CUIIDIN CU1na the l'lll)0nlllll
a. In custody the 1st of the month
b. In custody the last day of the month
c. ended the nrnnram durinn the month <for anv reason\
:a_ T.--·-1n111a1-
a. Clients receiving face-to.face contact 72 hours or less after enrollment
a. Clients receivino face-to.face contact 72 hours or more after enrollment
a.-·---a. Number of clients billed to Medi-Cal and SB163 Trust
b. Number of clients billed onlv to the SB163 Trust
Ill.
Clients enrolled for O • 3 months
Clients enrolled for 3 -6 months
Clients enrolled for 6 -12 months
Clients enrolled for over 12 months
Clients enrolled for 18+ months/All of these need to be tracked in the Notes Tab\
~ -o1 111-, 168+&,,t&:l
a. Counseling/Therapy provided by SB163 Provider staff
b. Counseling/Therapy provided by Star, MHS or CPI
c. Counselioo/Theraov orovided bv Countv Mental Heatth Staff
Exltina from Proaram ..
a. Goal Achievement
b. Dependency dismissed at youth's request (of age)
c. Reunification was successful and dependency was dismissed
d. Retumed to out of home care (higher level of care)
e. Subsequent removal due to abuse
f. In JJC custody/youth rearrested
g. Dissatisfied with services/voluntarily disenrolled
h. Fanily declined intensive service
I. Services no longer needed to meet educational needs (IEP)
j. Moved out of area
k. AWOURan awav
12_ ,_.,
a. Clients enrolled for O -3 months
b. Clients enrolled for 3 -6 months
c. Clients enrolled for 6 -12 months
d. Clients enrolled for 12-18 months
e. Clients enrolled for 18+ months
Katie A Mandates
a. Number of Clients who received an ICC Meeting
b. Number of Clients who received an IHBS Service
c. Number of Teamina Meetinns attended with CWS
CLIENT DEMOGRAPHICS <For current month)
a. Total number of Hispanic or Latino clients
b. Total number of White clients
c. Total number of Black or African American
d. Ta al number of Asian clients
e . Total number clients of an ethnicity not defined by the above categories
f. Total number female clients
g. Total number male clients
h. Total number of clients residing with parenV relative
I. Total number of clients residina with foster care nrovider
COMMENTS: PLEASE PLACE ANY COMMENTS OR NOTES IN THE NOTES TAB. THANK YOU
Jan
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
I 0
I 0
I 0
0
0
0
0
0
0
0
0
0
ExhibitH
I Feb I ... I Dll I -I -f ·-I ft.I I
0 0 0 0 n n 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 n 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 n n n
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0 0 0 0
0 0 0 IJ n ft
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0 0 0 0 0 0 0
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0 0 0 0 0 0 0
0 0 0 0 0 0 n
0 0 0 u 0 n 0
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0 0 D 0 0 0 0
0 0 0 0 0 0 n
0 0 a n n n
0 0 0 0 0 0 0
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 n
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 D 0, n "" n
0 0 D 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 D 0 0 0 n
0 I 0 I 0 I 0 0 0 I 0
I 0 I 0 0 I 0 0 0 I 0
I 0 I 0 0 I 0 0 0 I n
0 0 0 0 0 0 0
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
Exhibit I
Page 1 of 2
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business
and Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with all
State of California and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements at 42, Code
of Federal Regulations sections 2.1 et seq; California Welfare and Institutions
Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the
California Health and Safety Code; Title 22, California Code of Regulations,
section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates
of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment.
C. Suspension of Compensation
Exhibit I
Page 2 of 2
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
Medi-Cal Organizational Provider Standards
Exhibit J
Page 1 of 2
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.
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.
Exhibit J
Page 2 of 2
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation, the
provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Health Care
Service's day treatment requirements. The COUNTY shall review the provider's written
program description for compliance with the State Department of Health Care Service's day
treatment requirements.
12. The COUNTY may accept the host county's site certification and reserves the right to
conduct an on-site certification review at least every three (3) years. The COUNTY may
also conduct additional certification reviews when:
The provider makes major staffing changes.
J 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.
7 There are significant changes in the physical plant of the provider site (some physical
plant changes could require a new fire clearance).
J There is change of ownership or location.
I There are complaints against the provider.
1 There are unusual events, accidents, or injuries requiring medical treatment for clients,
staff or members of the community.
Fresno County Mental Health Plan
Grievances
Exhibit K
Page 1 of 2
The 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 to give verbal and written information to Medi-Cal beneficiaries regarding the
following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance form, an
appeal form, and Request for Change of Provider Form. All of these beneficiary materials must
be posted in prominent locations where Medi-Cal beneficiaries receive outpatient specialty
mental health services, including the waiting rooms of providers' offices of service.
Please note that all fee-for-service providers and contract agencies are required to give their
clients copies of all current beneficiary information annually at the time their treatment plans are
updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without any penalty,
change in mental health services, or any form of retaliation. All Medi-Cal beneficiaries can file
an appeal or state hearing.
Grievances and appeals forms and self-addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written request.
Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider concerns and
problems regarding payment authorization issues, other complaints and concerns.
Informal provider problem resolution process -the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
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).
Exhibit K
Page 2 of 2
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 ninety
(90) calendar days of the date of the receipt of the non-approval of payment.
The MHP shall have sixty (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 Managed Care staff who were 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 thirty (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 sixty (60) calendar days of receipt
of the complaint. The decision rendered buy the MHP is final.
FRESNO COUNTY MENTAL HEAL TH PLAN
INCIDENT REPORTING
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
Exhibit L
Page 1 of 2
• 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.
• VVhen more than one client is involved in an incident. a separate form must be completed for each client.
VVhere the forms should be sent -within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
INCIDENT REPORT WORKSHEET
VI/hen did this happen? (date/time)
Name/DMH#
________ VI/here did this happen?
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
VI/ho was affected? (If other than consumer)
list key people involved. (witnesses, visitors, physicians, employees)
Exhibit L
Page 2 of 2
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write comments on an 8
1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent O inconsequential D consequential D death D not applicable D unknown 0
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) _________________ Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit M
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
CERTIFICATION
Exhibit M
2 of 2
( 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:
(Printed Name & Title)
Date:
(Name of Agency or
Company)
SELF-DEALING TRANSACTION DISCLOSURE FORM
Exhibit N
Page 1 of2
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).
(1) Company Board Member Information:
Name: I I Date: I
Job Title: I I I
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
Exhibit N
Page 2 of 2
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 6233
(a)
(61 Authorized Sianature
Signature: I I Date: I
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. ldenf in Information
Name of entity 0/B/A
Exhibit 0
Page 1 of 2
Address (number, street} Crty State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and
addresses of individuals or corporations under "Remarks" on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
by Titles XVIII, XIX, or XX? ........................................................................................................................ .
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ..................................................................................... .
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution's, organization's, or
agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) .......... .
YES NO
0 0
a a
Ill. 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: a Sole proprietorship o Partnership CJ Corporation
o Unincorporated Associations a 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 .......................................................................................................... . CJ CJ
NAME ADDRESS PROVIDER NUMBER
IV. A. Has there been a change in ownership or control within the last year? ...................................................... .
If yes, give date.
B. Do you anticipate any change of ownership or control within the year? ...................................................... .
If yes, when? ___________________ _
C. Do you anticipate filing for bankruptcy within the year? ............................................................................... .
If yes, when? ___________________ _
V. Is the facility operated by a management company or leased in whole or part by another organization? ......... .
If yes, give date of change in operations. ___________ _
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year? ........ .
VII. A. Is this facility chain affiliated? ..................................................................................................................... .
If es, list name, address of cor oration, and EIN.
Name EIN
Address (number, name) City State
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
ZIP code
Exhibit 0
Page 2 of 2
YES NO
a a
CJ CJ
a a
a CJ
a CJ
a a
Whoever knowingly and w/1/fully 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 autllorized representative (typed) Tille
Signature Date
Remarks
Monthly Progress Report
Children's Wraparound Program
SW Name/Phone No:
DPO Name/Phone No:
Facilitator/Phone No:
Therapist/Phone No:
Parent/Guardian:
Updated Phone No:
Updated Home Address:
I Family's Big Goal:
ISP: O In Progress 0 Approved On: __
CFT MEMBERS IN ATTENDANCE:
1. What's Working?
2. Immediate Needs & Concerns:
3. Family updates & progress since last CFT mtg:
4. School/Work Updates:
5. Compliance with court mandates:
6. Facilitator updates:
7. Counselor updates:
8. Parent Partner updates:
9. Youth Partner updates:
10. Other T earn Supports & Misc updates:
11. Next CFT meeting date/time/location:
Exhibit P
Page 1 of 1
YOUTH:
CFT DATE:
WRAP Team:
• Facilitator:
• Parent Partner:
• Counselor:
• Youth Partner:
• MSW Intern:
Discharge Presentation
(Enter Case Name)
DIC: (Date)
Section One: Demographics
• Child's Name: :
• Date of Birth:
• Enrollment Date:
• Discharge Date:
Section Two: Referral to Wraparound
A. Reason for referral to the WRAP Program:
B. Youth and Family Strengths:
C. Youth and Family Challenges
Section Three: Participation in Wraparound Services
Section Four: Current Stability of Youth/Family and Linkages
A. Current stability of Youth and Family
8. Linkages, Resources and Natural Supports
Exhibit Q
Page 1 of 1
ICFP Presentation Outline
Exhibit R
Page 1 of 1
1. Provide Demographic Information (child's age, gender, grade, school attending,
IEP, Mental health services).
• Name:
• Date of Birth:
• School:
• IEP:
• Last Annual IEP:
• Mental Health Services:
• Diagnosis:
• Mediations:
2. Provide relevant family information, including brief description of caregiver(s}
(Foster Family, Birth Family, Mentor, etc.).
• Foster Parent/s:
• Foster Home:
• Biological Mother:
• Presumed Biological Father:
3. Provide Reason for referral to Wraparound:
• Enrollment Date:
• History of Placements:
• Reason for Referral:
Individual Child and Family Plan (ICFP) Youth's Name: I Referred By (CW, Probation, DBH, AAP): Life Domains: check all domains that will be addressed in ICFP D Safety D Legal D Family D Relationship D School D Emotional Housing D Finances D Medical/Health D Work D Cultural D Spiritual D Social/Fun Family's Big Goal: NEEDS& Exhibit S Page 1 of 2 D D Other LIFE DOMAIN CONCERNS STRENGTHS STRATEGY RESOURCES School Spiritual Emotional Other
Signatures Required for Approval: Parent/Guardian Signature Date Youth's Signature Facilitator Date System Partner (SW, DPO, DMH) Counselor Date Parent Partner, if available Youth's Partner, if available Date Therapist, if available Other Team Members Date Other Team Members Plan has been reviewed and approved by (Supervisor's Signature): Date Date Date Date Date Exhibit S Page 2 of 2