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Agreement No. 15-209
MASTER AGREEMENT
This Agreement is made and entered into this 2nd day of __ J=u=n=e __ _,, 2015, by and
between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
referred to as "COUNTY", and each CONTRACTOR listed in Exhibit A, attached hereto and by this
reference incorporated herein, and collectively hereinafter referred to as "CONTRACTORS", and
such additional CONTRACTOR(S) as may, from time to time during the term of this Agreement, be
added by COUNTY, with the Department ofBehavioral Health (DBH) Director or designee approval.
Reference in this Agreement to "parties" shall be understood to refer to COUNTY and each individual
CONTRACTOR, unless otherwise specified.
WITNESSETH:
WHEREAS, COUNTY, through its DBH, Mental Health Services Act (MHSA), Prevention and
Early Intervention (PEl) component, recognizes the need to provide Prevention and Early Intervention
School Based Programs (PEISBP) Kindergarten through Twelfth Grade, as specified in this
Agreement and as part of Fresno County's approved State PEI Plan, to help reduce stigma and
discrimination against mental illness and provide services related to mental well being and mental
health services; and
WHEREAS, CONTRACTOR(S) are 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, th~ parties
hereto agree as follows:
1. SERVICES
CONTRACTOR(S) shall perform all services and fulfill all responsibilities set forth in
its Exhibit B (Fresno County Office of Special Education Local Plan Area Scope ofWork) attached
hereto and by this reference incorporated herein and made part of this Agreement.
2. TERM
This Agreement shall become effective on the 1st day of July, 2015 and shall terminate
on the 301h day of June, 2018.
This Agreement, subject to State funding each year, and subject to satisfactory
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1 performance outcomes as identified in Exhibit B, shall be extended annually for two (2) additional
2 twelve (12) month periods upon the same terms and conditions herein set forth, unless written notice
3 of non-renewal is given by COUNTY, CONTRACTOR(S), or COUNTY's DBH Director or designee,
4 not later than sixty (60) days prior to the renewal period.
5 3. TERMINATION
6 A. Non-Allocation of Funds-The terms of this Agreement, and the services to be
7 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
8 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
9 terminated at any time by giving the CONTRACTOR(S) thirty (30) days advance written notice.
1 0 B. Breach of Contract -The COUNTY may immediately suspend or terminate this
11 Agreement in whole or in part, where in the determination of the COUNTY there is:
12 1) An illegal or improper use of funds;
13 2) A failure to comply with any term of this Agreement;
14 3) A substantially incorrect or incomplete report submitted to the
15 COUNTY;
16 4) Improperly performed service.
1 7 In no event shall any payment by the COUNTY constitute a waiver by the
18 COUNTY of any breach of this Agreement or any default which may then exist on the part of the
19 CONTRACTOR(S). Neither shall such payment impair or prejudice any remedy available to the
2 0 COUNTY with respect to the breach or default. The COUNTY shall have the right to demand of the
21 CONTRACTOR(S) the repayment to the COUNTY of any funds disbursed to CONTRACTOR(S)
2 2 under this Agreement, which in the judgment of the COUNTY were not expended in accordance with
2 3 the terms of this Agreement. CONTRACTOR(S) shall promptly refund any such funds upon demand
2 4 or, at COUNTY's option; such repayment shall be deducted from future payments owing to
2 5 CONTRACTOR(S) under this Agreement.
2 6 C. Without Cause -Under circumstances other than those set forth above, this
2 7 Agreement may be terminated by CONTRACTOR(S) or COUNTY or COUNTY's DBH Director, or
2 8 designee, upon the giving of sixty (60) days advance written notice of an intention to terminate.
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CONTRACTOR(S) may terminate with appropriate sixty (60) days advance written
notice of intent to terminate transmitted by CONTRACTOR(S) to COUNTY by Certified U.S. Mail,
Return Receipt Requested, addressed to the office of COUNTY as follows:
4. COMPENSATION
Director (or designee)
County of Fresno
Department of Behavioral Health
P.O. Box 45003
Fresno, CA 93718-9886
9 COUNTY agrees to pay CONTRACTORS and CONTRACTORS agree to receive
10 compensation in accordance with the expenses set forth within each CONTRACTOR's respective
11 Budget, not to exceed Five Hundred Twenty-Nine Thousand Fifty-One and No/1 00 Dollars
12 ($529,051.00) for each twelve (12) month period for all CONTRACTOR(S).
13 The maximum compensation amount under this Agreement for each of the twelve month
14 optional renewal periods of: July 1, 2018 through June 30, 2019; and July 1, 2019 through June 30,
15 2020 shall not exceed Five Hundred Twenty-Nine Thousand Fifty-One and No/100 Dollars
16 ($529,051.00) for all CONTRACTOR(S).
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A. The maximum amounts paid to each CONTRACTOR identified in the
Agreement are stated within each CONTRACTOR's respective Budget, attached hereto and by this
reference incozporated herein as Exhibit C. It is understood by all parties that the COUNTY's
contribution to this program is limited to MHSA funds only and not to other program revenues that
may be generated by CONTRACTOR(S).
B. It is understood that all expenses incidental to CONTRACTOR(S) performance
of services under this Agreement shall be borne by CONTRACTOR(S). If CONTRACTOR(S) fails to
comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
c. Payments shall be made by COUNTY to CONTRACTOR(S) in arrears, for
services provided during the preceding month, within forty-five (45) days after the date of receipt by
COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made
after receipt and verification of actual expenditures incurred by CONTRACTOR(S) in the
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1 performance of this Agreement and shall be documented to COUNTY on a monthly basis by the tenth
2 (l01h) of the month following the month of said expenditures.
3 D. COUNTY shall not be obligated to make any payments under this Agreement if
4 the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
5 terminated or expired.
6 E. Any compensation not consumed by expenditures of CONTRACTOR(S) by the
7 expiration or termination date of this Agreement shall be remitted to COUNTY within sixty (60) days
8 of expiration or termination of said Agreement.
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F. COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S) agrees to
receive compensation based upon actual expenditures incurred by CONTRACTOR(S) for monthly
program costs, in accordance with the narrative and budget identified in Exhibit C, as appropriate
"Budgets", attached hereto and by this reference incorporated herein. Subsequent Revised Exhibit C
"Budgets" may later replace current Exhibit C "Budgets" if agreed upon in writing by both parties.
G. CONTRACTOR(S) shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR(S) deficiency discovered through the State
audit process. At COUNTY's election, the disallowed amount will be remitted within forty-five (45)
days to COUNTY upon notification or shall be withheld from subsequent payments to
CONTRACTOR(S).
H. In the event that funding for these services is delayed by the State Controller,
COUNTY may defer payment to CONTRACTOR(S). The amount of the deferred payment shall not
exceed the amount of funding delayed by the State Controller to the COUNTY. The period of time of
the deferral by COUNTY shall not exceed the period of time of the State Controller's delay of
payment to COUNTY plus forty-five (45) days.
I. Yearly budget( s) beginning for FY 2016-17 to be provided herein shall be
submitted for review for each subsequent term ofthe Agreement to COUNTY's DBH Director or
designee for approval. Said budget(s) shall be submitted for review and requires the approval of
COUNTY's DBH Director or designee prior to March I st of each term of this Agreement. If said
budget is not received by the March I st due date, the current budget will remain at the then current
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1 funding level. The compensation amount of said approved budget(s) shall not exceed the maximum
2 compensation of the current Agreement term.
3 5. INVOICING
4 A. CONTRACTOR(S) shall invoice COUNTY monthly by the 1 01h of the following
5 month, via post office mail, addressed to the County of Fresno, Department of Behavioral Health,
6 Mental Health Services Act, 3133 N. Millbrook Ave., Fresno, California, 93703, Attention: PEl-K-
7 12 PBIS MHSA Contract Analyst or via email at DBHinvoices@co.fresno.ca.us. Said invoices shall
8 include applicable supporting documentation in detail such as dates of services, actual expenditures,
9 and amount(s) invoiced for the month. Invoices shall be subject to County, State of California, and
10 Federal audits. Invoices are to be received and reviewed by Mental Health Contracted Services, Staff
11 Analyst.
12 B. No Reimbursement for actual services rendered under this Agreement shall be
13 made until said invoices, as identified above, are received and reviewed by COUNTY's DBH.
14 COUNTY agrees to reimburse CONTRACTOR in arrears, within forty-five days after receipt and
15 verification of CONTRACTOR's monthly invoices by COUNTY's DBH. If monthly invoices or
16 supporting documentation are incorrect or otherwise not in proper form or substance, COUNTY shall
1 7 have the right to withhold payment as to only that portion of the monthly invoice or supporting
18 documentation that is incorrect or improper.
19 6. INDEPENDENT CONTRACTOR
2 0 In performance of the work, duties, and obligations assumed by CONTRACTOR(S)
21 under this Agreement, it is mutually understood and agreed that CONTRACTOR(S), including any
22 and all ofCONTRACTOR(S)'s officers, agents, and employees will at all times be acting and
2 3 performing as an independent contractor, and shall act in an independent capacity and not as an
2 4 officer, agent, servant, employee, joint venturer, partner, or associate of the COUNTY. Furthermore,
2 5 COUNTY shall have no right to control or supervise or direct the manner or method by which
2 6 CONTRACTOR(S) shall perform its work and function. However, COUNTY shall retain the right to
2 7 administer this Agreement so as to verify that CONTRACTOR(S) is performing its obligations in
2 8 accordance with the terms and conditions thereof. CONTRACTOR(S) and COUNTY shall comply
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with all applicable provisions of law and the rules and regulations, if any, of governmental authorities
having jurisdiction over matters which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR(S) shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CONTRACTOR(S) shall be solely liable and responsible for providing to, or on behalf of, its
employees all legally-required employee benefits. In addition, CONTRACTOR(S) shall be solely
responsible and save COUNTY harmless from all matters relating to payment of CONTRACTOR(S)'s
employees, including compliance with Social Security, withholding, and all other regulations
governing such matters. It is acknowledged that during the term of this Agreement,
CONTRACTOR(S) may be providing services to others unrelated to the COUNTY or to this
Agreement.
7. MODIFICATION
13 Any matters of this Agreement may be modified from time to time by the written
14 consent of all the parties without, in any way, affecting the remainder.
15 Notwithstanding the above, changes to line items in the budgets, attached hereto as
16 Exhibit Cas appropriate, that do not exceed 10% of the individual CONTRACTOR(S)'s program total
17 maximum compensation payable to CONTRACTOR(S), may be made with the written approval of
18 COUNTY's DBH Director or designee and CONTRACTOR(S). Said budget line item changes shall
19 not result in any change to the individual CONTRACTOR(S)'s program maximum compensation
2 0 amount payable to CONTRACTOR(S), as stated herein.
21 Additions to Exhibit A "List of Contractors" may be made with written approval of
22 COUNTY's DBH Director or designee, upon COUNTY's DBH Director or designee having received
2 3 and approved submitted proposals for additional PEISBP CONTRACTOR(S) and/or PEISBP sites.
2 4 Proposals for the inclusion of PEISBP CONTRACTOR(S) and/or PEISBP sites must be prepared and
2 5 submitted in accordance with Exhibit B to: County of Fresno, Department of Behavioral Health,
2 6 Mental Health Services Act, 3133 N. Millbrook A venue, Fresno, CA 93 703, Attention: MHSA PEl
2 7 K-12 PBIS Contract Analyst.
2 8 8. NON-ASSIGNMENT
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Neither party shall assign, transfer or subcontract this Agreement nor their rights or
duties under this Agreement without the prior written consent of the other party.
9. HOLD-HARMLESS
CONTRACTOR(S) agrees to indemnify, save, hold harmless, and at COUNTY's
request, defend the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR(S), its
officers, agents or employees under this Agreement, and from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
any person, firm or corporation who may be injured or damaged by the performance, or failure to
perform, of CONTRACTOR(S), its officers, agents or employees under this Agreement.
CONTRACTOR(S) agrees to indemnify COUNTY for Federal, State of California and/or
local audit exceptions resulting from noncompliance herein on the part of the CONTRACTOR(S).
10. INSURANCE
Without limiting the COUNTY's right to obtain indemnification from
CONTRACTOR(S) or any third parties, CONTRACTOR(S), at its sole expense, shall maintain in full
force and effect the following insurance policies or program of self-insurance, including but not
limited to, an insurance pooling arrangement or Joint Powers Agreement (JPA) throughout the term of
this Agreement:
A.
B.
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.
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
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c.
D.
E.
F.
combined single limit of One Million Dollars ($1,000,000). Coverage should
include owned and non-owned vehicles used in connection with this Agreement.
Personal Property
CONTRACTOR(S) 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 property as discussed in Section Nineteen (19) of this Agreement.
Professional Liability
IfCONTRACTOR(S) employs licensed professional staff(e.g. Ph.D., R.N.,
L.C.S.W., L.M.F.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.
Child Abuse/Molestation and Social Services Coverage
CONTRACTOR shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability. The
policy limits for these policies shall be $1,000,000 per occurrence with
$2,000,000 annual aggregate. The policies are to be on a per occurrence basis.
CONTRACTOR(S) shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by the COUNTY, its officers, agents and employees shall be
excess only and not contributing with insurance provided under the CONTRACTOR(S) 's policies
herein. This insurance shall not be cancelled or changed without a minimum of thirty (30) days
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1 advance written notice given to COUNTY.
2 Within thirty {30) days from the date CONTRACTOR(S) signs this Agreement,
3 CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of
4 the foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health,
5 Mental Health Services Act, 3133 N. Millbrook Ave., Fresno, California, 93703, Attention: PEIPBIS
6 Contract Analyst, stating that such insurance coverage's have been obtained and are in full force; that
7 the County of Fresno, its officers, agents and employees will not be responsible for any premiums on
8 the policies; that such Commercial General Liability insurance names the County of Fresno, its
9 officers, agents and employees, individually and collectively, as additional insured, but only insofar as
1 0 the operations under this Agreement are concerned; that such coverage for additional insured shall
11 apply as primary insurance and any other insurance, or self-insurance, maintained by the COUNTY,
12 its officers, agents and employees, shall be excess only and not contributing with insurance provided
13 under the CONTRACTOR(S)'s policies herein; and that this insurance shall not be cancelled or
14 changed without a minimum of thirty (30) days advance, written notice given to COUNTY.
15 In the event CONTRACTOR(S) fails to keep in effect at all times insurance coverage as
16 herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate
1 7 this Agreement upon the occurrence of such event.
18 All policies shall be with admitted insurers licensed to do business in the State of
19 California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
2 0 of A FSC VII or better.
21 11. CONFIDENTIALITY
2 2 All services performed by CONTRACTOR(S) under this Agreement shall be in strict
2 3 conformance with all applicable Federal, State of California and/or local laws and regulations relating
2 4 to confidentiality.
25 12. LICENSES/CERTIFICATES
2 6 Throughout each term of this Agreement, CONTRACTOR(S) and CONTRACTOR(S)'s
2 7 staff 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(S) shall notify COUNTY immediately in writing of its
3 inability to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions
4 irrespective ofthe pendency of any appeal related thereto. Additionally, CONTRACTOR(S) and
5 CONTRACTOR(S)'s staff shall comply with all applicable laws, rules or regulations, as may now
6 exist or be hereafter changed.
7 13. REPORTS
8 A. Monthly Reports-CONTRACTOR(S) shall submit to COUNTY's DBH by the
9 tenth (1 01h) of each month all monthly activity and budget reports for the preceding month.
10 In addition, CONTRACTOR(S) shall also furnish to COUNTY such statements,
11 records, reports, data, and other information as COUNTY may request pertaining to matters covered
12 by this Agreement. In the event that CONTRACTOR(S) fails to provide such reports or other
13 information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly
14 payments until there is compliance. In addition, CONTRACTOR(S) shall provide written notification
15 and explanation to COUNTY within five ( 5) days of any funds received from another source to
16 conduct the same services covered by this Agreement.
17 B. Quarterly Report Progress Updates-CONTRACTOR(S) shall complete all
18 Quarterly Report Progress updates according to the State Department of Mental Health regulations in
19 accordance with Exhibit D "Quarterly Progress Goals and Report", attached hereto and incorporated
2 0 herein by reference. CONTRACTOR(S) shall utilize the "Current Quarterly Progress Report
21 Overview" instruction sheet as shown in Exhibit E-State Quarterly Progress Report instructions,
2 2 attached hereto and incorporated herein by reference, to submit the Quarterly Report Progress updates
2 3 referenced in Exhibit D. All quarterly reporting is to be submitted to the DBH's Contracted Services
2 4 Unit within thirty (30) days of quarter ending for review by COUNTY'S Contracted Services unit.
25 14. MONITORING
2 6 CONTRACTOR(S) agrees to extend to COUNTY's staff, COUNTY's DBH Director
2 7 and the State Department of Health Care Services, or their designees, the right to review and monitor
2 8 records, program or procedures, at any time, in regard to clients, as well as the overall operation of
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1 CONTRACTOR(S)'s program, in order to ensure compliance with the terms and conditions of this
2 Agreement.
3 15. REFERENCES TO LAWS AND RULES
4 In the event any law, regulation, or policy referred to in this Agreement is amended
5 during the term thereof, the parties hereto agree to comply with the amended provision as of the
6 effective date of such amendment.
7 16. COMPLIANCE WITH STATE REQUIREMENTS
8 CONTRACTOR(S) recognizes that COUNTY operates its mental health programs
9 under an agreement with the State of California Department of Health Care Services, and that under
10 said agreement the State imposes certain requirements on COUNTY and its subcontractors.
11 CONTRACTOR(S) shall adhere to all State Requirements, including those identified in Exhibit F
12 "State Mental Health Requirements", attached hereto and by this reference incorporated herein.
13 17. DATA SECURITY
14 For the purpose of preventing the potential loss, misappropriation or inadvertent access,
15 viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
16 of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
1 7 enter into a contractual relationship with the COUNTY for the purpose of providing services under
18 this Agreement must employ adequate data security measures to protect the confidential information
19 provided to CONTRACTOR(S) by the COUNTY, including but not limited to the following~
20 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
21 CONTRACTOR(S) may not connect to COUNTY networks via personally-
2 2 owned mobile, wireless or handheld devices, unless the following conditions are met
23 1)
2 4 telecommuting purposes;
2)
3)
4)
CONTRACTOR(S) has received authorization by COUNTY for
Current virus protection software is in place;
Mobile device has the remote wipe feature enabled; and
A secure connection is used.
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28 B. CONTRACTOR-Owned Computers or Computer Peripherals
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CONTRACTOR(S) may not bring CONTRACTOR(S)-owned computers or
computer peripherals into the COUNTY for use without prior authorization from the COUNTY's
Chief Information Officer, and/or designee(s), including but not limited to mobile storage devices. If
data is approved to be transferred, data must be stored on a secure server approved by the COUNTY
and transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
8 CONTRACTOR(S) may not use COUNTY computers or computer peripherals
9 on non-COUNTY premises without prior authorization from the COUNTY's Chieflnformation
10 Officer, and/or designee(s).
11 D. CONTRACTOR(S) may not store COUNTY's private, confidential or sensitive
12 data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
13 E. CONTRACTOR(S) shall be responsible to employ strict controls to ensure the
14 integrity and security of COUNTY's confidential information and to prevent unauthorized access,
15 viewing, use or disclosure of data maintained in computer files, program documentation, data
16 processing systems, data files and data processing equipment which stores or processes COUNTY
1 7 data internally and externally.
18 F. Confidential client information transmitted to one party by the other by means of
19 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
2 0 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
21 G. CONTRACTOR(S) is responsible to immediately notify COUNTY of any
2 2 violations, breaches or potential breaches of security related to COUNTY's confidential information,
2 3 data maintained in computer files, program documentation, data processing systems, data files and
2 4 data processing equipment which stores or processes COUNTY data internally or externally.
25 H. COUNTY shall provide oversight to CONTRACTOR(S)'s response to all
2 6 incidents arising from a possible breach of security related to COUNTY's confidential client
2 7 information provided to CONTRACTOR(S). CONTRACTOR(S) will be responsible to issue any
2 8 notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole
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discretion. CONTRACTOR(S) will be responsible for all costs incurred as a result of providing the
required notification.
18. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A. The parties to this Agreement shall be in strict conformance with all applicable
5 Federal and State of California laws and regulations, including but not limited to Sections 5328,
6 10850, and 14100.2 et seq. of the Welfare and Institutions Code, Sections 2.1 and 431.300 et seq. of
7 Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the California Civil Code, Sections
8 11977 and 11812 ofTitle 22 ofthe California Code of Regulations, and the Health Insurance
9 Portability and Accountability Act (HIP AA), including but not limited to Section 1320 D et seq. of
1 0 Title 42, United States Code (USC) and its implementing regulations, including, but not limited to
11 Title 45, CFR, Sections 142, 160, 162, and 164, and The Health Information Technology for
12 Economic and Clinical Health Act (HITECH) regarding the confidentiality and security of patient
13 information.
14 Except as otherwise provided in this Agreement, CONTRACTOR(S), as a
15 Business Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform
16 functions, activities or services for or on behalf of COUNTY, as specified in this Agreement, provided
17 that such use or disclosure shall not violate the HIPAA, USC 1320d et seq. The uses and disclosures
18 of PHI may not be more expansive than those applicable to COUNTY, as the "Covered Entity" under
19 the HIP AA Privacy Rule ( 45 CFR 164.500 et seq), except as authorized for management,
2 0 administrative or legal responsibilities of the Business Associate.
21 B. CONTRACTOR(S) shall protect, from unauthorized access, use, or disclosure of
2 2 names and other identifying information concerning persons receiving services pursuant to this
2 3 Agreement, except where permitted in order to carry out data aggregation purposes for health care
2 4 operations [45 CFR Sections 164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)]-This
2 5 pertains to any and all persons receiving services pursuant to a COUNTY funded program.
2 6 CONTRACTOR(S) shall not use such identifying information for any purpose other than carrying out
2 7 CONTRACTOR(S)' s obligations under this Agreement.
28 C. CONTRACTOR(S) shall not disclose any such identifying information to any
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1 person or entity, except as otherwise specifically permitted by this Agreement, authorized by law, or
2 authorized by the client/patient.
3 D. For purposes of the above sections, identifying information shall include, but not
4 be limited to name, identifying number, symbol, or other identifying particular assigned to the
5 individual, such as finger or voice print, or a photograph.
6 E. CONTRACTOR(S) shall provide access, at the request of COUNTY, and in the
7 time and manner designated by COUNTY, to PHI in a designated record set (as defmed in 45 CFR
8 Section 164.501 ), to an individual or to COUNTY in order to meet the requirements of 45 CFR
9 Section164.524 regarding access by individuals to their PHI.
10 CONTRACTOR(S) shall make any amendment(s) to PHI in a designated record
11 set at the request of COUNTY, and in the time and manner designated by COUNTY in accordance
12 with 45 CFR Section 164.526.
13 CONTRACTOR(S) shall provide to COUNTY or to an individual, in a time and
14 manner designated by COUNTY, information collected in accordance with 45 CFR Section 164.528,
15 to permit COUNTY to respond to a request by the individual for an accounting of disclosures of PHI
16 in accordance with 45 CFR Section 164.528.
17 F. CONTRACTOR(S) shall report to COUNTY, in writing, any knowledge or
18 reasonable belief that there has been unauthorized access, viewing, use, disclosure, or breach of
19 Protected Information not permitted by this Agreement, and any breach of unsecured PHI of which it
2 0 becomes aware, immediately and without reasonable delay and in no case later than two (2) business
21 days of discovery. Immediate notification shall be made to COUNTY's Information Security Officer
22 and Privacy Officer and COUNTY's DBH HIPAA Representative, within two (2) business days of
2 3 discovery. The notification shall include, to the extent possible, the identification of each individual
2 4 whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, used,
2 5 disclosed, or breached. CONTRACTOR(S) shall take prompt corrective action to cure any
2 6 deficiencies and any action pertaining to such unauthorized disclosure required by applicable Federal
2 7 and State Laws and regulations. CONTRACTOR(S) shall investigate such breach and is responsible
2 8 for all notifications required by law and regulation or deemed necessary by COUNTY and shall
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1 provide a written report of the investigation and reporting required to COUNTY's Information
2 Security Officer and Privacy Officer and COUNTY's DBH HIPAA Representative. This written
3 investigation and description of any reporting necessary shall be postmarked within the thirty (30)
4 working days of the discovery of the breach to the addresses below:
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County of Fresno
Department of Behavioral Health
HIP AA Representative
(559) 453-4809
4441 E. Kings Canyon
Fresno, CA 93702
County of Fresno
Dept. ofPublic Health
Privacy Officer
(559) 445-3249
1221 Fulton Mall
Fresno, CA 93721
County of Fresno
Information Technology Services
Information Security Officer
(559) 600-5800
2048 N. Fine Ave
Fresno, CA 93727
G. CONTRACTOR(S) shall make its internal practices, books, and records relating
to the use and disclosure of PHI received from COUNTY, or created or received by the
CONTRACTOR(S) on behalf of COUNTY, available to the United States Department of Health and
Human Services upon demand.
H. Safeguards
CONTRACTOR(S) shall implement administrative, physical, and technical
safeguards as required by 45 CFR 164.308, 164.310, and 164.312 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 COUNTY; and to prevent access, use or disclosure of
PHI other than as provided for by this Agreement. CONTRACTOR(S) shall develop and maintain a
written information privacy and security program that includes administrative, technical and physical
safeguards appropriate to the size and complexity ofCONTRACTOR(S)'s operations and the nature
and scope of its activities. Upon COUNTY's request, CONTRACTOR(S) shall provide COUNTY
with information concerning such safeguards.
CONTRACTOR(S) shall implement strong access controls and other security
safeguards and precautions in order to restrict logical and physical access to confidential, personal
(e.g., PHI) or sensitive data to authorized users only. Said safeguards and precautions shall include
the following administrative and technical password controls for all systems used to process or store
confidential, personal, or sensitive data:
1. Passwords must not be:
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1 a. Shared or written down where they are accessible or recognizable
2 by anyone else; such as taped to computer screens, stored under keyboards, or visible in a work area;
3 b. A dictionary word; or
4 c. Stored in clear text
5 2. Passwords must be:
6 a. Eight (8) characters or more in length;
7 b. Changed every ninety (90) days;
8 c. Changed immediately if revealed or compromised; and
9 d. Composed of characters from at least three of the following four
1 0 groups from the standard keyboard:
11 1) Upper case letters (A -Z);
12 2) Lowercase letters (a-z);
13 3) Arabic numerals (0 through 9); and
14 4) Non-alphanumeric characters (punctuation symbols).
15 CONTRACTOR(S) shall implement the following security controls on each
16 workstation or portable computing device (e.g., laptop computer) containing confidential,
personal, or sensitive data:
1.
2.
Network-based firewall and/or personal firewall;
Continuously updated anti-virus software; and
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21 system/software vendor security patches.
2 2 CONTRACTOR(S) shall utilize a commercial encryption solution that has
2 3 received FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on
2 4 portable electronic media (including, but not limited to, compact disks and thumb drives) and on
2 5 portable computing devices (including, but not limited to, laptop and notebook computers).
2 6 CONTRACTOR(S) shall not transmit confidential, personal, or sensitive data via
2 7 e-mail or other internet transport protocol unless the data is encrypted by a solution that has been
2 8 validated by the National Institute of Standards and Technology (NIST) as conforming to the
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1 Advanced Encryption Standard (AES) Algorithm.
2 I. Mitigation of Harmful Effects
3 CONTRACTOR(S) shall mitigate, to the extent practicable, any harmful effect
4 that is known to CONTRACTOR(S) of an unauthorized access, viewing, use, disclosure, or breach of
5 PHI by CONTRACTOR(S) or its subcontractors in violation of the requirements of these provisions.
6 J. Contractor's Subcontractors
7 CONTRACTOR(S) shall ensure that any of its contractors, including
8 subcontractors, if applicable, to whom CONTRACTOR(S) provides PHI received from or created or
9 received by CONTRACTOR(S) on behalf of COUNTY, agree to the same restrictions and conditions
10 that apply to CONTRACTOR(S) with respect to such PHI; and to incorporate, when applicable, the
11 relevant provisions of these provisions into each subcontract or sub-award to such agents or
12 subcontractors ..
13 K. Employee Training and Discipline
14 CONTRACTOR(S) shall train and use reasonable measures to ensure
15 compliance with the requirements of these provisions by employees who assist in the performance of
16 functions or activities on behalf of COUNTY under this Agreement and use or disclose PHI and
1 7 discipline such employees who intentionally violate any provisions of these provisions, including
18 termination of employment.
19 L. Termination for Cause
20 Upon COUNTY's knowledge of a material breach ofthese provisions by
21 CONTRACTOR(S), COUNTY shall either:
22 1. Provide an opportunity for CONTRACTOR(S) to cure the breach or end
2 3 the violation and terminate this Agreement if CONTRACTOR does not cure the breach or end the
2 4 violation within the time specified by COUNTY; or
25 2. Immediately terminate this Agreement if CONTRACTOR(S) has
2 6 breached a material term of these provisions and cure is not possible.
27 3. If neither cure nor termination is feasible, the COUNTY Privacy Officer
2 8 shall report the violation to the Secretary of the U.S. Department of Health and Human Services.
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M. Judicial or Administrative Proceedings
COUNTY may terminate this Agreement in accordance with the terms and
conditions of this Agreement as written hereinabove, if: (1) CONTRACTOR(S) 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(S) has violated a privacy or security standard or
requirement of the HITECH Act, HIP AA; or other security or privacy laws in an administrative or
civil proceeding in which the CONTRACTOR(S) is a party.
N. Effect of Termination
9 Upon termination or expiration of this Agreement for any reason,
1 0 CONTRACTOR(S) shall return or destroy all PHI received from COUNTY (or created or received by
11 CONTRACTOR(S) on behalfofCOUNTY) that CONTRACTOR(S) still maintains in any form, and
12 shall retain no copies of such PHI. If return or destruction of PHI is not feasible, it shall continue to
13 extend the protections of these provisions to such information, and limit further use of such PHI to
14 those purposes that make the return or destruction of such PHI infeasible. This provision shall apply
15 to PHI that is in the possession of subcontractors or agents, if applicable, of CONTRACTOR(S). If
16 Contractor destroys the PHI data, a certification of date and time of destruction shall be provided to
17 the COUNTY by CONTRACTOR(S).
18 0. Disclaimer
19 COUNTY makes no warranty or representation that compliance by
2 0 CONTRACTOR(S) with these provisions, the HITECH Act, HIP AA or the HIP AA regulations will be
21 adequate or satisfactory for CONTRACTOR(S)' s own purposes or that any information in
22 CONTRACTOR(S)'s possession or control, or transmitted or received by CONTRACTOR(S), is or
2 3 will be secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR(S) is
2 4 solely responsible for all decisions made by CONTRACTOR(S) regarding the safeguarding of PHI.
25 P. Amendment
2 6 The parties acknowledge that Federal and State laws relating to electronic data
2 7 security and privacy are rapidly evolving and that amendment of these provisions may be required to
2 8 provide for procedures to ensure compliance with such developments. The parties specifically agree
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1 to take such action as is necessary to amend this agreement in order to implement the standards and
2 requirements of HIP AA, the HIP AA regulations, the HITECH Act and other applicable laws relating
3 to the security or privacy of PHI. COUNTY may terminate this Agreement upon thirty (30) days
4 written notice in the event that CONTRACTOR(S) does not enter into an amendment providing
5 assurances regarding the safeguarding of PHI that COUNTY in its sole discretion deems sufficient to
6 satisfY the standards and requirements of HIP AA, the HIP AA regulations and the HITECH Act.
7 Q. No Third-Party Beneficiaries
8 Nothing express or implied in the terms and conditions of these provisions is
9 intended to confer, nor shall anything herein confer, upon any person other than COUNTY or
1 0 CONTRACTOR(S) and their respective successors or assignees, any rights, remedies, obligations or
11 liabilities whatsoever.
12 R. Interpretation
13 The terms and conditions in these provisions shall be interpreted as broadly as
14 necessary to implement and comply with HIPAA, the HIP AA regulations and applicable State laws.
15 The parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved
16 in favor of a meaning that complies and is consistent with HIP AA and the HIP AA regulations.
17 s. Regulatory References
18 A reference in the terms and conditions of these provisions to a section in the
19 HIP AA regulations means the section as in effect or as amended.
20 T. Survival
21 The respective rights and obligations of CONTRACTOR(S) as stated in this
2 2 Section shall survive the termination or expiration of this Agreement.
23 u. No Waiver of Obligations
2 4 No change, waiver or discharge of any liability or obligation hereunder on any
2 5 one or more occasions shall be deemed a waiver of performance of any continuing or other obligation,
2 6 or shall prohibit enforcement of any obligation on any other occasion.
27 19. PROPERTY OF COUNTY
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1 A. COUNTY and CONTRACTOR recognizes that fixed assets are tangible and
2 intangible property obtained or controlled under COUNTY's Mental Health Plan for use in operational
3 capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified
4 items will be on a straight-line basis.
5 For COUNTY purposes, fixed assets must fulfill three qualifications:
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Asset must have life span of over one 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
o equipment
o vehicles
• or intangible asset
o Internally generated software
o Purchased software
o Easements
o Patents
• and capital lease
Threshold
$0
$100,000
$100,000
$5,000
$100,000
$5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it
is approved and identified as an asset it will be tagged with a COUNTY program number. A fixed
asset log will be maintained by COUNTY's Asset Management System and annually inventoried until
the asset is fully depreciated. During the terms of this Agreement, CONTRACTOR's fixed assets may
be inventoried in comparison to COUNTY's DBH Asset Inventory System.
B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than One Thousand and No/100 Dollars ($1,000.00), with over one year life span, and are
mobile and high risk of theft or loss are sensitive assets. Such sensitive items are not limited to
computers, copiers, televisions, cameras and other sensitive items as determined by COUNTY's DBH
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1 Director or designee. CONTRACTOR maintains a tracking system on the items and are not required
2 to be capitalize or depreciated. The items are subject to annual inventory for compliance.
3 c. Assets shall be retained by COUNTY, as COUNTY property, in the event this
4 Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate
5 in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration
6 of this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
7 returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
8 COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
9 unable to produce the assets at the expiration or termination of this Agreement.
1 0 CONTRACTOR further agrees to the following:
11 1. To maintain all items of equipment in good working order and condition,
12 normal wear and tear is expected;
13 2. To label all items of equipment with COUNTY assigned program number,
14 to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
15 where and how the equipment is being used, in accordance with procedures developed by COUNTY.
16 All such lists shall be submitted to COUNTY within ten (1 0) days of any request therefore; and
17 3. To report in writing to COUNTY immediately after discovery, the lost or
18 theft of any items of equipment. For stolen items, the local law enforcement agency must be
19 contacted and a copy of the police report submitted to COUNTY.
20 D. The purchase of any equipment by CONTRACTOR with funds provided
21 hereunder shall require the prior written approval of COUNTY's DBH, shall fulfill the provisions of
2 2 this Agreement as appropriate, and must be directly related to CONTRACTOR's services or activity
2 3 under the terms of this Agreement. COUNTY's DBH may refuse reimbursement for any costs
2 4 resulting from equipment purchased, which are incurred by CONTRACTOR, if prior written approval
2 5 has not been obtained from COUNTY.
26 E. CONTRACTOR must obtain prior written approval from COUNTY's DBH
2 7 whenever there is any modification or change in the use of any property acquired or improved, in
2 8 whole or in part, using funds under this agreement. If any real or personal property acquired or
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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 Nineteen (19) 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."
20. NON-DISCRIMINATION
10 During the performance of this Agreement CONTRACTOR(S) shall not unlawfully
11 discriminate against any employee or applicant for employment, or recipient of services, because of
12 race, religion, color, national origin, ancestry, physical disability, medical condition, marital status,
13 age or gender, pursuant to all applicable State of California and Federal statutes and regulations.
14 21. SEPARATE AGREEMENT
15 It is mutually understood by the parties that this Agreement does not, in any way, create
16 a joint venture among CONTRACTOR(S). By execution of this Agreement, CONTRACTOR(S)
1 7 understand that a separate Agreement is formed between each individual CONTRACTOR and
18 COUNTY.
19 22. ENGLISH PROFICIENCY
2 0 CONTRACTOR(S) shall provide interpreting and translation services to persons
21 participating in CONTRACTOR(S)'s services who have limited or no English language proficiency,
2 2 including services to persons who are deaf or blind. Interpreter and translation services shall be
2 3 provided as necessary to allow such participants meaningful access to the programs, services and
2 4 benefits provided by CONTRACTOR(S). Interpreter and translation services, including translation of
2 5 CONTRACTOR(S)'s "vital documents" (those documents that contain information that is critical for
2 6 accessing CONTRACTOR(S)'s services or are required by law) shall be provided to participants at no
2 7 cost to the participant. CONTRACTOR(S) shall ensure that any employees, agents, subcontractors, or
2 8 partners who interpret or translate for a program participant, or who directly communicate with a
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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)' s services.
23. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under Section
1861 (v) (1) (1) of the Social Security Act. (42 U.S.C. § 139x, subd. (v)(l){l}). until the expiration of
four ( 4) years after the furnishing of services under this Agreement, CONTRACTOR(S) shall make
available upon written request of the Secretary of the United States Department of Health and Human
Services, or upon request ofthe Comptroller General of the United States General Accounting Office,
or any of their duly authorized representatives, a copy of this Agreement and such books, documents,
and records as are necessary to certifY the nature and extent of the costs of these services provided by
CONTRACTOR(S) under this Agreement. CONTRACTOR(S) further agrees that in the event
CONTRACTOR(S) carries out any of its duties under this Agreement through a subcontract, with a
value or cost ofTen Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month
period, with a related organization, such Agreement shall contain a clause to the effect that until the
expiration of four ( 4) years after the furnishing of such services pursuant to such subcontract, the
related organizations shall make available, upon written request of the Secretary ofthe United States
Department of Health and Human Services, or upon request ofthe Comptroller General of the United
States General Accounting Office, or any of their duly authorized representatives, a copy of such
subcontract and such books, documents, and records of such organization as are necessary to verify the
nature and extent of such costs.
24. SINGIJE AUDIT CLAUSE
A. If CONTRACTOR(S) expends Seven Hundred Fifty Thousand Dollars
2 4 ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR(S) agrees to
2 5 conduct an annual audit in accordance with the requirements of the Single Audit Standards as set forth
26 in Office of Management and Budget (OMB) Circular A-133. CONTRACTOR(S) shall submit said
2 7 audit and management letter to COUNTY. The audit must include a statement of findings or a
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1 include a corrective action plan signed by an authorized individual. CONTRACTOR(S) agrees to take
2 action to correct any material non-compliance or weakness found as a result of such audit. Such audit
3 shall be delivered to COUNTY's DBH Business Office for review within nine (9) months of the end
4 of any fiscal year in which funds were expended and/or received for the program. Failure to perform
5 the requisite audit functions as required by this Agreement may result in COUNTY performing the
6 necessary audit tasks, or at COUNTY's option, contracting with a public accountant to perform said
7 audit, or, may result in the inability of COUNTY to enter into future agreements with
8 CONTRACTOR(S). All audit costs related to this Agreement are the sole responsibility of
9 CONTRACTOR(S).
10 B. A single audit report is not applicable ifCONTRACTOR(S)'s Federal contracts
11 do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or
12 CONTRACTOR(S)'s only funding is through Drug related Medi-Cal. If a single audit is not
13 applicable, a program audit must be performed and a program audit report with management letter
14 shall be submitted by CONTRACTOR(S) to COUNTY as a minimum requirement to attest to
15 CONTRACTOR's solvency. Said audit report shall be delivered to COUNTY's DBH Business Office
16 for review, no later than nine (9) months after the close of the fiscal year in which the funds supplied
17 through this Agreement are expended. Failure to comply with this Act may result in COUNTY
18 performing the necessary audit tasks or contracting with a qualified accountant to perform said audit.
19 All audit costs related to this Agreement are the sole responsibility of CONTRACTOR(S) who agrees
2 0 to take corrective action to eliminate any material noncompliance or weakness found as a result of
21 such audit. Audit work performed by COUNTY under this section shall be billed to the
22 CONTRACTOR(s) at COUNTY's cost, as determined by COUNTY's Auditor-Controller/Treasurer-
2 3 Tax Collector.
24 c. CONTRACTOR(S) shall make available all records and accounts for inspection
25 by COUNTY, the State of California, if applicable, the Comptroller General ofthe United States, the
2 6 Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
2 7 period of at least three (3) years following tina] payment lmder this Agreement or the closure of all
2 8 other pending matters, whichever is later.
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25. COMPLIANCE -"CONTRACTOR CODE OF CONDUCT AND ETHICS"
CONTRACTOR(S) agrees to comply with COUNTY's Mental Health Plan Compliance
Program and Policy and Procedure, "Contractor Code of Conduct and Ethics", and COUNTY's
"Fresno County Mental Health Compliance Program Contractor Acknowledgement and Agreement,"
both attached hereto as Exhibit G, and by this reference incorporated herein. Within thirty (30) days
of entering into this Agreement with COUNTY, CONTRACTOR(S) shall have all of
CONTRACTOR(S)'s employees, agents and subcontractors providing services under this Agreement
certify in writing, that he or she has received, read, understood, and shall abide by the "Contractor
Code of Conduct and Ethics". CONTRACTOR(S) shall ensure that within thirty (30) days of hire, all
new employees, agents and subcontractors providing services under this Agreement shall certify in
writing that he or she has received, read, understood, and shall abide by the "Contactor Code of
Conduct and Ethics." CONTRACTOR(S) understands that the promotion of and adherence to the
"Contractor Code of Conduct and Ethics" is an element in evaluating the performance of
CONTRACTOR(S) and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training; and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractor shall attend the appropriate training within thirty (30) days of hire. Each individual who
is required to attend training shall certify, in writing, that he or she has received the required training.
The certification shall be provided to COUNTY's Compliance Officer at 3133 N. Millbrook Avenue,
Fresno, California 93703.
26. ASSURANCES
A. In entering into this Agreement, CONTRACTOR(S) certifies that it is not
2 5 currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health
2 6 Care Programs; that it has not been convicted of a criminal offense related to the provision of health
2 7 care items or services; nor has it been reinstated to participation in the Federal Health Care Programs
2 8 after a period of exclusion, suspension, debarment, or ineligibility. If COUNTY learns, subsequent to
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entering into contract, that CONTRACTOR(S) is ineligible on these grounds, COUNTY will remove
CONTRACTOR(S) from responsibility for, or involvement with COUNTY's business operations
related to the Federal Health Care Programs until such time CONTRACTOR(S) is reinstated into
participation in the Federal Health Care Programs and shall remove such CONTRACTOR(S) from any
position in which CONTRACTOR(S)'s compensation, or the items or services rendered, ordered or
prescribed by CONTRACTOR(s) may be paid in whole or part, directly or indirectly, by Federal
Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR(S) is
reinstated into participation in the Federal Health Care Programs.
B. If COUNTY has notice that CONTRACTOR(S) has been charged with a criminal
10 offense related to any Federal Health Care Program, or is proposed for exclusion during the term on
11 any contract, CONTRACTOR(S) and COUNTY shall take all appropriate actions to ensure the
12 accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
13 circumstances, COUNTY may request that CONTRACTOR(S) cease providing services until
14 resolution of the charges or the proposed exclusion.
15 C. CONTRACTOR(S) agrees that all potential new employees of
16 CONTRACTOR(S) or subcontractors of CONTRACTOR(S) who, in each case, are expected to
17 perform professional services under this Agreement, will be queried as to whether (1) they are now or
18 ever have been excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
19 Health Care Programs; (2) they have been convicted of criminal offense related to the provision of
2 0 health care items or services; and/or (3) they have been reinstated to participation in the Federal Health
21 Care Programs after a period of exclusion, suspension, debarment, or ineligibility.
2 2 1. In the event the potential employee or subcontractor informs
2 3 CONTRACTOR(S) that he or she is excluded, suspended, debarred or otherwise ineligible, or has
2 4 been convicted of a criminal offense relating to the provision of health care services, and
2 5 CONTRACTOR(S) hires or engages such potential employee or subcontractor, CONTRACTOR(S)
2 6 will ensure that said employee or subcontractor does not work, either directly or indirectly, relating to
2 7 services provided to COUNTY.
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2. Notwithstanding any other provision of this Agreement, COUNTY at its
discretion may terminate this Agreement in accordance with Paragraph 3 hereof, or require adequate
assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible individual
will perform work, either directly or indirectly, relating to services provided to COUNTY. Such
demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY to
protect the interests of COUNTY clients.
D. CONTRACTOR(S) shall verify (by asking the applicable employees and
8 subcontractors) that all current employees and existing subcontractors who, in each case, are expected
9 to perform professional services under this Agreement; (a) are not currently excluded, suspended,
1 0 debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (b) have not been
11 convicted of a criminal offense related to the provision of health care items or services; and (c) have not
12 been reinstated to participation in the Federal Health Care Program after a period of exclusion,
13 suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
14 CONTRACTOR(S) that he or she is excluded, suspended, debarred or otherwise ineligible to
15 participate in the Federal Health Care Programs, or has been convicted of a criminal offense relating to
16 the provision of health care services, CONTRACTOR(S) will ensure that said employee or
17 subcontractor does not work, either directly or indirectly, relating to services provided to COUNTY.
18 1. CONTRACTOR(S) agrees to notify COUNTY immediately during the
19 term of this Agreement whenever CONTRACTOR(S)'s engagement partner under this Agreement
2 0 learns that an employee or subcontractor who, in each case, is providing professional services under
21 this Agreement is excluded, suspended, debarred or otherwise ineligible to participate in the Federal
2 2 Health Care Programs, or is convicted of a criminal offense relating to the provision of health care
2 3 services.
24 2. Notwithstanding the above, COUNTY at its discretion may terminate this
2 5 Agreement in accordance with the Termination Section of this Agreement, or require adequate
2 6 assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
2 7 subcontractor of CONTRACTOR(S) will perform work, either directly or indirectly, relating to
2 8 services provided to COUNTY. Such demand for adequate assurance shall be effective upon a time
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1 frame to be determined by COUNTY to protect the interests of COUNTY clients.
2 E. CONTRACTOR(S) agrees to cooperate fully with any reasonable requests for
3 information from COUNTY which may be necessary to complete any internal or external audits
4 relating to this Agreement.
5 F. CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any
6 penalty imposed upon COUNTY by the Federal Government as a result ofCONTRACTOR(S)'s
7 violation ofCONTRACTOR(S)'s obligations as described in this Section.
8 27. DISCLOSURE -CRIMINAL HISTORY AND CIVIL ACTIONS
9 CONTRACTOR(S) is required to disclose if any of the following conditions apply to
1 0 them, their owners, officers, corporate managers and partners:
11 A. Within the three-year period preceding the Agreement award, they have been
12 convicted of, or had a civil judgment rendered against them for:
13 1. Fraud or a criminal offense in connection with obtaining, attempting to
14 obtain, or performing a public (federal, state, or local) transaction or contract under a public
15 transaction;
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2.
3.
4.
Violation of a federal or state antitrust statute;
Embezzlement, theft, forgery, bribery, falsification, or destruction of
False statements or receipt of stolen property.
Within a three-year period preceding their Agreement award, they have had a
21 public transaction (federal, state, or local) terminated for cause or default.
2 2 Disclosure of the above information will not automatically eliminate
2 3 CONTRACTOR(S) from further business consideration. The information will be considered as part
2 4 of the determination of whether to continue and/or renew the contract and any additional
2 5 information or explanation that a CONTRACTOR(S) elects to submit with the disclosed information
2 6 will be considered. If it is later determined that the CONTRACTOR(S) failed to disclose required
2 7 information, any contract awarded to such CONTRACTOR(S) may be immediately voided and
2 8 terminated for material failure to comply with the terms and conditions of the award.
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CONTRACTOR(S) must sign an appropriate "Certification Regarding Debarment,
Suspension, and Other Responsibility Matters", Exhibit H, attached hereto and by this reference
incorporated herein. Additionally, CONTRACTOR(S) must immediately advise the COUNTY in
writing if, during the term of the agreement: (1) CONTRACTOR(S) becomes suspended, debarred,
excluded or ineligible for participation in federal or state funded programs or from receiving federal
funds as listed in the excluded parties list system (http://www.sam.gov); or (2) any of the above listed
conditions become applicable to CONTRACTOR(S). The CONTRACTOR(S) will indemnify, defend
and hold the COUNTY harmless for any loss or damage resulting from a conviction, debarment,
exclusion, ineligibility or other matter listed in the signed Certification Regarding Debarment,
Suspension, and Other Responsibility Matters.
28. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
12 INFORMATION
13 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
14 managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104,
15 and455.106(a)(1),{2).
16 In accordance with C.P.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
17 the following information must be disclosed by CONTRACTOR by completing Exhibit I, "Disclosure
18 of Ownership and Control Interest Statement", attached hereto and by this reference incorporated
19 herein and made part of this Agreement. CONTRACTOR shall submit this form to COUNTY's DBH
2 0 within thirty (30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall
21 report any changes to this information within thirty-five (35) days of occurrence by completing
22 Exhibit I, "Disclosure ofOwnership and Control Interest Statement." Submissions shall be scanned
2 3 pdf copies and are to be sent via email to DBHAdministration@co.fresno.ca.us attention: Contracts
2 4 Administration.
25 29. DISCLOSURE OF SELF-DEALING TRANSACTIONS
2 6 This provision is only applicable if the CONTRACTOR is operating as a corporation (a
2 7 for-profit or non-profit corporation) or if during the term of this agreement, the CONTRACTOR
2 8 changes its status to operate as a corporation.
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Members of the CONTRACTOR's Board ofDirectors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the
CONTRACTOR is a party and in which one or more of its directors has a material financial interest.
Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
by completing and signing a Self-Dealing Transaction Disclosure Form (Exhibit J attached hereto and
by this reference incorporated herein and made part of this Agreement) and submitting it to the
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
30. AUDITS AND INSPECTIONS
10 The CONTRACTOR(S) shall at any time during business hours, and as often as the
11 COUNTY may deem necessary, make available to the COUNTY for examination all of its records and
12 data with respect to the matters covered by this Agreement. The CONTRACTOR(S) shall, upon
13 request by the COUNTY, permit the COUNTY to audit and inspect all such records and data
14 necessary to ensure CONTRACTOR(S)'s compliance with the terms of this Agreement.
15 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
16 CONTRACTOR(S) shall be subject to the examination and audit of the State Auditor General for a
17 period of three (3) years after final payment under contract (Government Code section 8546.7).
18 31. PROHIBITION ON PUBLICITY
19 None of the funds, materials, property or services provided directly or indirectly under
2 0 this Agreement shall be used for CONTRACTOR(S)'s advertising, fundraising, or publicity (i.e.,
21 purchasing tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
22 Notwithstanding the above, publicity of the services described in Section One (1) of this Agreement
2 3 shall be allowed as necessary to raise public awareness about the availability of such specific services
2 4 when approved in advance by COUNTY's DBH Director or designee and at a cost to be provided in
2 5 Exhibit C as appropriate, attached hereto, for such items as written/printed materials, the use of media
2 6 (i.e., radio, television, newspapers) and any other related expense(s).
27 32.
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COMPLAINTS
CONTRACTOR(S) shall log complaints and the disposition of all complaints from a
-30 -COUN'lY OF FRESNO
l;rcsno, CA
1 client or a client's family. CONTRACTOR(S) shall provide a copy of the detailed complaint log
2 entries concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10 1h)
3 day of the following month, in a format that is mutually agreed upon. Besides the detailed complaint
4 log, CONTRACTOR(S) shall provide details and attach documentation of each complaint with the
5 log. CONTRACTOR(S) shall post signs informing client of their right to file a complaint or
6 grievance. CONTRACTOR(S) shall notify COUNTY of all incidents reportable to state licensing
7 bodies that affect COUNTY clients within twenty-four (24) hours of receipt of a complaint as
8 indicated in Exhibit K "Fresno County mental Health Plan", attached hereto and by this reference
9 incorporated herein. CONTRACTOR shall file an incident report for all incidents involving clients,
1 0 following the Protocol and using the Worksheet identified in Exhibit L.
11 33. NOTICES
12 The persons having authority to give and receive notices under this Agreement and their
13 addresses include the following:
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COUNTY CONTRACTOR(S)
Director, Fresno County (See Exhibit A)
Department of Behavioral Health
4441 E. Kings Canyon Rd
Fresno, CA 93702
18 Any and all notices between the COUNTY and the CONTRACTOR(S) provided for or
19 permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
2 0 personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
21 United States Mail, postage prepaid, addressed to such party.
22 34. GOVERNING LAW
2 3 The parties agree, that for the purposes of venue, performance under this Agreement is
2 4 to be in Fresno County, California.
2 5 The rights and obligations of the parties and all interpretation and performance of this
2 6 Agreement shall be governed in all respects by the laws of the State of California.
27 35.
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ENTIRE AGREEMENT
This Agreement and including all Exhibits between the CONTRACTOR(S) and
-31 -COUNlY OF FRESNO
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1 COUNTY with respect to the subject matter hereof and supersedes all previous agreement
2 negotiations, proposals, commitments, writings, advertisements, publications, and understandings of
3 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.
ATTEST:
CONTRACTOR(S)
PLEASE SEE EXHffiiT A,
Attached hereto
COUNTY OF FRESNO
By~~LU~~~~~~~~~~~
Chairman, Board of Supervisors
6/t/ti Date:
I I
BERNICE E. SEIDEL, Clerk
Board of Supervisors
Date: ":Ii.A..tr4--~ /)J)/5
I
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
-33 -COUNTY OF FRESNO
Fresno, CA
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APPROVED AS TO LEGAL FORM:
DANIEL CEDERBORG, COUNTY COUNSEL
By {i1~
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
Byo~~
REVIEWED AND RECO ENDED
FOR APPROVAL:
By~~
Dawan Utecht, Director
Department of Behavioral Health
Fund/Subclass: 0001110000
Organization: 56304324
Account/Program: 7294/0
Fiscal Year (FY)
FY 2015-16
FY 2016-17
FY 2017-18
FY 2018-19
FY 2019-20
Program Cost
$529,051
$529,051
$529,051
$529,051
$529,051
-34 -
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
COUN1YOF FRESNO
Fresno, CA
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FRESNO COUNTY OFFICE OF EDUCATION
SPECIAL ED CATION LOCAL PLAN AREA (SELPA)
Title: ___________ _
By
Chairman of the Board, or
President, or any Vice President
7?~'1"-A~
Print Name: J;,~h_JI\.~ r1./t7C... TI;V
Title:~rr>t ~ptU?t~ T!?Al'tJMT
Secre ry (of Cotporatwn), or
any Assistant Secretary, or
ChiefFinancial Officer, or
any Assistant Treasurer
Mailing Address:
1111 Van Ness
Fresno, CA 93 721
Phone No.: (559) 265-4027
Contact: Erik Nyberg
-35 -COUN'JY OF FRESNO
Fresno, CA
Exhibit A
(PBIS Districts Schools)
District School Cohort
Caruthers Unified School District Caruthers Elementary School I
McKinley Elementary School
Rio Vista Middle School
Steinbeck Elementary School I
Teague Elementary School
Polk (James K.) Element;>ry School
Harvest Elementa_ry School
Herndon Elementarv School
Madison Elementary School
Norman Liddell Elementary School II River Bluff Elementary School
Roosevelt Elementary School
Central Unified School District Saroyan (William) Elementary School
Glacier Point Middle School
PathwaY Community Day School
Biola-Pershing Elementary School
Central High School West Campus Ill Central High School East Campus
Houghton-Kearney Elementary School
El Capitan Middle School IV
Pathway Elementary School
Pershing Continuation High School v Pathway Community Day School
Han Phan Tilley Elementary School
Centerville Elementary
Del Rey Elementary
Fairmont Elementary
Jackson Elementary
Jefferson Elementary
Lincoln Elementary
Lone Star Elementary
Madison Elementary II
Sanger Unfied School District
Reagan Elementary
Sequoia Elementary
JohnS. Wash Elementary
Wilson Elementary
Quail Lake Charter
Sanger Acacdemy Charter
Washinaton Academic Middle School
Sang~r High School Ill
Community Day School IV Kings River High School
Cantua Elementary School
Helm Elementary School IV
San Joaquin Elementary School
Golden Plains Unified School District Tranquillity Elementary School
Rio Del Rey Continuation High Schoo v Tranquillity High School
Bailey (Hazel M.) Primary School
Firebaugh-Las Deltas Joint Unified School Firebaugh High School I
District Mills (Arthur E.) Intermediate School
Firebaugh Middle School
Fremont Elementary School
Malaga Elementary School IV
Fowler Unified Schoof District Marshall Elementary School
John Sutter Middle School v Fowler High School
Raisin City Elementary School District Raisin City Elementary School IV
Sierra Unified School District Foothill Elementary School v
Kermit Koontz Education Center I
Fresno County Office of Education ED & TIES Program
Alice Worsley Ill
Violet Heintz Education Academy
McCabe Elementary School Ill
Mendota Unified School District Washington Elementary School
Mendota Elementary School v
Nell Dawson Elementary School Sunset Elementary IV
Bishop Elementary School
Coalinga-Huron Joint Unified School District Coalinga Middle School
Cheney Kindergarten School v
Huron Elementary School
Huron Middle School
Westside Elementary School District Westside Elemental)'_ School IV
Exhibit A
(PBIS Districts Schools)
District School Cohort
Kerman Unified School District Goldenrod Elementary School IV
liberty Intermediate School v
Citrus Middle School
Reedley High School I
Silas Bartsch School
Dunlap Elementary
McCord Elementary II
Reed Elementary
lincoln Elementary School
Navelencia Middle School
Oran•e Cove HJllh School Ill
Kings Canyon Unified School District Kings Canyon Continuation
Riverview Elementary School
Alta Elementary School
Conner A.L} Elementary School
IV Great Western Elementary School
Washington Elementary School
General Grant Middle School
Jefferson Elementary School v Sheridan Elementary School
Reedley High School
Kingsburg Joint Union High School District Kingsburg High School IV Oasis Continuation High School
Rafer Johnson Junior High School IV
Kingsburg Elementary Charter School District Kingsburg Elementary Charter v Ronald W. Reagan Elementary School
American Union Elementary School Ill West Fresno Middle School
Washington Unified School District West Fresno Elementary School IV
Washington Union High School v
Monroe Elementary School District Monroe Elementary School IV
Woodrow Wilson Elementary School I
Garfield (James) Elementary School
Indianola Elementary School
White (Eric) Elementary School
II
Terry Elementary School
Selma Unified School District Jackson Elementary School
Roosevelt Elementary School Ill
Washington Elementary School
Lincoln Elementary School
Heartland High School IV
Selma High School
Benavidez S. Ben Elementary School
Brletic Mathew J. Elementary School
Chavez (Cesar E.) Elementary School I
Parlier Unified School District Martinez (John C.) Elementary School
Parlier High School
Parlier Junior High School
San Joaquin Valley High School v
Oranae Center Elementary Orange Center Elementary School v
laton Unified School District laton Elementary/Conejo Middle School v
Clay Joint Elementary School District Clay Joint Elementary School v
Exhibit A
Fresno County Schools Not Yet Trained in PBIS
Caruthers Unified School District Caruthers High School
Coalinga-Huron Unified School District Coalinga High School
Kerman Floyd Elementary School
Kerman Unified School District Sun Empire Elementary School
Kerman Middle School
Kerman High School
Central Valley Home School
Island Community Day School
Kingsburg Elementary Charter School District Lincoln Elementary School
Roosevelt Elementary School
Washington Elementary School
Kings Canyon Unified School District Dunlap LeadershipAcadem't'
Laton Unified School District Laton High School
Mendota Unified School District Mendota High School
Pacific Union Elementary Pacific Union Elementary
Pine Ridge Elementary Pine Ridge Elementary
Fipps Primary
Riverdale Unified School District Riverdale Elementary School
Riverdale High School
Lodge Pole
Sierra Unified School District Pole Corral
Sierra Junior High
Sierra High School
Washington Colony Washi'!Bton Colony Elementary School
West Park Elementary_ West Park Elementary
Exhibit B
FRESNO COUNTY OFFICE OF EDUCATION SPECIAL EDUCATION LOCAL PLAN
AREA (SELPA)
POSITIVE BEHAVIOR INTERVENTION & SUPPORTS (PBIS)
SCOPE OF WORK
CONTRACT SERVICES: PEl School Based Programs Kindergarten -12'h Grade
CONTRACT TERM: July 1, 2015-June 30, 2018, and
Two (2) optional Twelve (12) month periods
CONTRACT SITES: See Exhibit A
CONTRACT MAXIMUM: Fiscal Year
2015 -16
2016-17
2017-18
2018-19
2019-20
Organization Management & Capacity
Contract Maximum
$466,379
$466,379
$466,379
$466,379
$466,379
The Fresno County SELPA is a collaborative body that supports 32 Local Educational
Agency's and their students receiving special education services. In 2008, the Fresno County
SELPA established a collaborative committee to discuss and address the minimal resources
supporting students with intensive behavioral challenges. The goal of the collaborative
committee was to address educational outcomes for students with severe emotional and /
behavioral disabilities by: increasing the behavioral competency of teachers and parents;
creating positive and safe climates at school; using data-based decision making; and research
validated practices for interventions. Thorough analysis of evidence-based systems and
interventions led the committee towards Positive Behavioral Interventions and Supports.
In 2009, Fresno County Positive Behavior Interventions and Supports (PBIS) was created with
the support from the California Technical Assistance Center on PBIS and the National PBIS
Technical Assistance Center from University of Oregon and University of Connecticut. From
2010 to present, 100 K-8 schools in Fresno County have been trained or are currently
undergoing PBIS training. The Fresno County model includes mental health prevention
strategies, early identification of at-risk students, a continuum of care (primary, secondary,
and tertiary), and frequent assessment of progress.
There are 100 K-8 schools in the Fresno County SELPA area that have committed to scaling-
up PBIS over the past five years. Of the 100 schools, a large majority are rural schools typical
of underserved and/or un-served communities. Of the 100 schools, 28 are still completing
their three year training cycle. These 100 schools do not include high schools within Fresno
County, which have also been participating in PBIS training, but did not previously fall under
the scope of the RFP. To date, 4 high schools have completed training and there are 17 high
schools still in their three year cycle of training. Overall, there are 28 K-12 1h grade schools
remaining in Fresno County who have yet to be PSIS trained. The focus of our training for
2015-2020 is to train all remaining Fresno County schools in PBIS. The school teams from
Exhibit 8
each setting will determine and map the current evidence-based programs that best fits the
culture of the school-site. The PBIS schools will also establish a welcoming environment for
families and community agencies to provide services and supports based on school/student
needs and for students not responding to less intensive interventions.
Representatives from the Fresno County Office of Education, SELPA have been consistent
and active participants in being informed about Proposition 63 regulations and protocols. The
Fresno County Office of Education, SELPA understands that PEl is not a separate component
or framework, rather, PEl is an extension of the overall spectrum that can lead into the
treatment and recovery phase. It is further understood that programs funded under MHSA
PEl shall (a) demonstrate accountability to the public, (b) document process towards the
overall goals of PEl, (c) provide ongoing quality improvement functions, (d) engage
stakeholders and effective collaboration, (e) advance the mental health PEl functions, (f) be
objective in the decision-making, (h) communicate result in a timely manner, and (i) to be able
to regenerate the development of the PEl framework.
The Fresno County SELPA provides a wide range of services and supports for over 79,000
students and 32 LEAs in Fresno County. Many of the districts encompass clients and families
living in underserved rural areas. The general service plan for clients and families in
underserved areas includes working collaboratively with multiple schools throughout Fresno
County by establishing preventative systems for all students in the school setting. In order to
provide and scale-up the PBIS framework in schools residing in underserved areas, the
Districts' schools will agree to (a) active participation of site administration, (b) ensure that PBIS
is one of the site's top three goals, (c) provide a leadership team that is representative of the
school and teaching community, (d) provide a site-level PBIS coach, (e) use of the School-wide
Information System (SWIS) or an equivalent data collection program for behavioral progress
monitoring, (f) complete monthly reporting of behavioral data, and (g) commit to professional
development congruent with the implementation of an evidence-based practice. The district
shall provide substitute teachers, as needed and associated costs for participants.
In fulfilling the Fresno County SELPA's vision of creating the most inclusive learning
environments for all students and minimizing the potential onset of mental illnesses, the Fresno
County SELPA is committed to establishing a three-tiered integrated system in schools which
will link to tertiary interventions within the school and community systems of supports.
POSITIVE BEHAVIOR INTERVENTIONS & SUPPORT (PSIS} MODEL:
Positive Behavior Interventions and Support (PBIS) emphasizes the adoption of effective
systemic and individualized behavioral interventions for achieving important social, behavioral
and learning outcomes while preventing problem behaviors for all students (Center on PBIS,
2000). PBIS involves the integration of valued outcomes, data-based decision making, science
of human behavior, validated practices, and systems change procedures.
Positive Behavior Interventions and Supports (PBIS) is a proven approach to early identification
and intervention of behavior/emotional problems that provides opportunities for a partnership
between education and mental health services. The systems approach to establishing a
positive climate supports students experiencing onset of serious psychiatric illness, families
under stress, children and youth at risk for school failure and referrals to the juvenile justice
system. PBIS system encourages equal access to services, enables schools and their mental
health partners to meet the needs of at-risk children and youth in an efficient and effective way,
Exhibit B
decreases the stigma attached to mental health needs, and serves to diminish the effects of
cultural bias.
Interventions in the PSIS model are implemented in a three-tiered approach. There is school-
wide leadership for the development and implementation of the primary (school-wide)
prevention programs. The secondary or "targeted group" interventions are determined by
behavioral data and students receive additional intervention addressing their
emotional/behavioral needs. When the secondary prevention efforts are not sufficient, a
school professional is identified to facilitate the team in providing tertiary level support. This
tertiary support includes a functional behavioral assessment and the collaborative efforts of
other systems and organizations in addressing the treatment and recovery needs of the
student (for example: mental health services, private therapists, social workers, Juvenile
Justice, Probation, school nurses, and Individual Education Plan (IEP) teams).
Tier I (Universal): One goal will be to establish a Universal System in the schools with high
fidelity. School teams will meet for three (3) days to establish action plans and accountability
measurement tools to assist with creating a school-wide positive behavior support framework.
In addition, each team will have an internal PSIS coach to work with each school team.
External coaches from the FCOE office will provide additional support to the school teams. The
evidence-based practices to support school-wide practices will include (a) the development of
school-community behavioral statements of purpose, (b) identify positive school-wide behavioral
expectations, (c) develop procedures for school-wide expectations, (d) develop procedures for
teaching classroom-wide behavioral expectations, (e) develop continuum of procedures for
encouraging and strengthening student use of school-wide behavioral expectations, (f) develop
continuum of procedures for discouraging student behavior violations of school-wide behavioral
expectations, and (g) develop data-based procedures for monitoring implementation of school-
wide PSIS Universal Tier. When the school leadership team is engaging in the necessary
steps, the team will be able to use school-wide data to identify students who are not responding
to school-wide interventions.
Data is an essential component in all tiers, however, data obtained in tier I is particularly
important in order for school teams to make decisions in an efficient and preventative approach
before internal or external behaviors get worse. Schools will allocate one individual per district
from participating school teams to be trained as a School-wide Information System (SWIS)
facilitator. SWIS is web-based information system that is housed at the University of Oregon.
Confidentiality is a priority and will not be compromised. Using SWIS, teams will be able to
disseminate Office Discipline Referrals (ODRs) in order to make decisions. Examples of reports
provided by SWIS include referrals by location, average number of referrals per school site,
referrals by type of problem behavior, referrals by time of day, and referrals by individual
student. In addition, teams will be able to review the suspensions/expulsion data by student
ethnicity. As a general rule, students identified as having four (4) or more referrals will be
considered for small group intervention and students with six (6) or more referrals will be
considered for individualized intensive student supports. Additional information for SWIS can be
found at www.pbisapps.org.
Tier II (Secondarv): Positive Behavior Interventions and Supports schools will be instructed on
how to establish effective tier II (Secondary) early interventions that will address negative
behaviors of underserved populations within the school community. Teams will meet for two (2)
half days to identify evidence-based procedures for implementing effective interventions for
students not responding to school-wide positive behavior supports. When considering
secondary interventions for students not responding to universal interventions, teams will
Exhibit 8
evaluate the needs of the students and the available site-based resources and the skills of staff.
If a student does require additional support, the interventions considered shall be made up of
efficient behavior change strategies that are implemented in a consistent manner for groups of
students receiving the intervention. Data will be used to assist the team in determining the most
appropriate interventions and continuous progress monitoring. If a PSIS school does not have
an evidence-based secondary intervention, the schools will have the flexibility to choose
interventions. The schools will be provided criteria when considering the best evidence-based
secondary intervention for their school site. Examples of evidence-based secondary
interventions are Check and Connect, Check-in/Check-out, First Step to Success, and Think
Time (Horner, Sugai, & Anderson, 2010). Schools will be asked to build sustainable
infrastructures, time, and resources in order to receive funding for secondary interventions and
will provide a gap analysis of their school-based interventions.
Tier Ill (Tertiary Intervention): School teams will attend one half day of training during the
third year to revise or strengthen the schools tertiary intervention system. At this level,
functional based assessment and actions are implemented for students requiring intensive
level of interventions. The students will continue to receive the universal and secondary
interventions layered upon the appropriate intensive individualized interventions. Close
coordination between the schools and community based support services will be initiated
based upon the needs of the student. For instance, if the data and integrity of interventions
support more intensive interventions, the school can fluidly and efficiently access local
evidence-based support systems. The school leadership PSIS team will work closely with the
clinician or multiple agencies using a person-centered process to assist in forming
collaborative action plans. Monitoring progress is more frequent at this stage to ensure the
integrity of the interventions and evidence of student progress.
Sustainability Training: Once having completed the three year training cycle for PSIS, schools
will have an opportunity to participate in sustainability training. The goal of these trainings will be
to ensure the ongoing practice and implementation of PSIS at school sites, regardless of school
site staff or administration changes. School site, or district representatives, will attend these
sustainability trainings in order to receive ongoing support for PSIS implementation at their sites,
as well as continue to receive needed resources for the successful implementation of PSIS.
GOALS/OBJECTIVES:
PSIS integrated with mental health services can meet many of the objectives of Prevention and
Early Intervention (PEl) by supporting policymakers, school personnel and students. PSIS, in
partnership with mental health for identified students can:
• Improve the school's learning environment
• Address the social-emotional needs of all children
• Significantly reduce discipline problems
• Lead to improved academic outcomes and improved test scores
• Help children who cause frequent problems in school and for whom no one has found an
effective approach
• Reduce bullying and assist its victims
• Often lead to greater family participation in school and in the child's education.
• Increase access to mental health treatment
• Increase skills in problem solving
• Improve school failure: decrease in number of suspension and expulsions
Exhibit B
Target Population:
The PSIS system will focus on Children and Youth in school settings-Kindergarten through
Twelfth Grade. FCOE working with schools will allow for mental health systems to reach
children in need. For mental health systems, collaborating with PSIS schools can:
• Reach children who need care
• Include children at risk of serious mental disorders as well as those already exhibiting
significant problems
• Further the goals of interagency collaboration through systems of care
• Reduce the number of children with less severe problems who come in for care
(because prevention and early intervention practices have worked) and allow mental
health to focus attention on children with or at risk of having significant mental health
service needs
• Provide a vehicle for supporting children served by mental health systems whose
behavior in school is disruptive to learning or otherwise a problem
Fresno County SELPA will provide services for schools residing in un-served and underserved
areas within the county. Many of the schools for which the Fresno County SELPA provides
support to are rural communities with a large demographic of Hispanic/Latina children. Schools
are a natural setting in which large populations of children, youth, and families can be accessed.
Children are considered an un-served and underserved target population for accessing mental
health. The Education and Mental Health Project will create systems that both prevent and
allow school-community systems to integrate and work collaboratively.
Every student attending a school trained in implementing the prevention framework will
receive instruction in pro-social skills. Universal school-wide practices will be implemented in
instructional (i.e., classroom) and non-instructional (i.e., hallway, cafeteria, playground, bus,
etc.) areas of the school setting. Once a Universal (or Primary) system is implemented with
fidelity, the school leadership team will have established consistent criteria and procedures for
identifying students in need of additional social and behavioral supports based on the data.
CULTURAL COMPETENCY:
1. Cultural goals in policy-making: Currently, the research shows that discipline policy used by
schools has produced significant disparities when race and gender are disaggregated for the
use of out-of-school suspensions (Losen & Skiba, 2010). One goal of the PSIS trainings is to
create policies that eliminate the rate of disparities (academic and behavioral) between students
of color, and increase the level of opportunities for all students. The disparities associated with
access to mental health services is also of importance. Creating policies that emphasize the
use of data for decision making will alter how schools will determine how and when children and
youth can access prevention, early intervention, and individualized supports.
2. Cultural goals in program design: Each school site has its own established culture. What
may work in one school setting may not work in another school setting. Furthermore, the
context of each setting and the resources and staff knowledge must be taken into account when
implementing a program or intervention. As noted before, PSIS is NOT a program, intervention,
curriculum, or strategy. PSIS is a framework comprised of evidence-based practices and
organizational systems for establishing the social culture, learning and teaching environment,
and individualized supports. The Fresno County SELPA will emphasize establishing a
preventative infrastructure that is comprehensive and meets the contextual needs of each
setting. The Fresno County SELPA will not mandate that schools implement a specific program
Exhibit 8
if it is not needed, rather, the PSIS schools will determine on their own through a problem-
solving process what is working at their school site within each tier and establish action plans to
address the gaps within the continuum of supports. If a school brings in a new intervention or
program, they will follow specific criteria to choose the right evidence-base program and the
school will determine how to sustain the program and assess the applicability of the program in
accordance to the needs of their school culture. PSIS training curriculum will be modified from
time to time based on school needs. External coaches will be utilized to assist school sites
during periods of necessary adjustments.
3. Cultural goals in administration and service delivery: The current educational system reacts
after a child exhibits problems (academic or behavioral). All too often, the point of contact to
remediate student problems is too late within the trajectory of the student's development. This
can also exasperate the achievement gap and disparities to access effective mental health
services. For instance, a child who is expelled from school has a significantly higher probability
of entering the juvenile justice system or dropping out of school. This decreases equal access
to opportunities in the school and community. The staff also tries to counter problem behavior
by relying on experts' delivery. The organization often relies on outside experts'
recommendations. The expert leaves hoping that the staff is able to implement the
recommendations. The goal of training schools in establishing a prevention approach will be to
shift services from a "train and hope" perspective and move towards building systems of
supports (i.e., resources, training, policies) (Implementation Blueprint and Self-Assessment,
2010). The schools will establish systems that engage all students no matter how varying the
degrees of social or economic barriers. All staff (classified and certificated} will also take part in
the school-wide implementation process, emphasizing that the school as a community is
responsible for the success of every student.
COLLABORATION:
Through the PSIS site-based teams, local needs will be based on objective data. When the
data utilized by the PSIS teams indicates student and families may require more intensive
supports, the team will establish a coordinated procedure for comprehensive service delivery
by establishing a local network of existing resources. School staff is sometimes the first to
identify barriers within the students' families. All too often, the social and emotional barriers
experienced by the family may affect the student's ability to access education and quality
mental health services. When the data indicates the need for intensive mental health
supports for the student and/or family, the PSIS team (with the assistance of the PSIS Coach)
will be able to integrate representatives from outside agencies who are working closely with
the family/student to create a person-centered action plan. Fresno County MHSA programs
such as Community Services and Supports, MHSA School Based Rural and Metro Team, and
Kings View Youth Empowerment Centers are a few examples of local community supports
that can integrate within the teaming process.
PEl PERFORMANCE OUTCOME MEASURES:
The schools implementing the PSIS approach and supported by MHSA PEl funds will be
required to record the following outcome data. Fresno County Office of Education, SELPA will
have access to SWIS data and monitor it regularly.
How many students received:
• Evidence-based group interventions
Exhibit B
• Individual behavioral interventions
• One or more suspensions
Number of disciplinary incidents on a monthly basis:
• Minor referrals
• Major referrals
• Suspensions
• Expulsions Out of District
Definitions of Data:
1. Group evidence-based behavioral interventions: Examples include Check-In/Check-
Out, First Step to Success, Think Time, and social skills groups such as skill-
streaming, schedules to increase daily structure, contingencies for groups of
students, etc. (Horner, Sugai, & Anderson, 2010).
2. Individual behavioral interventions: function-based behavioral contracts and/or plans,
person-centered action plans, student study team plans, IEPs with behavior support plans,
referrals to Special Education for emotionally disturbed students., 504 Plans related to
student behavior, etc.
3. Total number of suspensions.
4. Total number of initial placements for Special Education services.
5. Minor referrals (# of incidents): include behavior which stops instruction and/or is
Teacher-Managed.
6. Major referrals(# of incidents): include behavior which is office-managed.
7. Number of suspensions(# of incidents): consequences for referrals result in a 1-3 day
period when student is not allowed on campus.
8. Expulsions (# of incidents): consequence for referrals results in student being expelled from
school.
Reporting Reguirements:
The Fresno County Office of Education, Special Education Local Plan Area will use research-
based measurement tools and qualitative methods in order to obtain data. Reporting
procedures to Fresno County Behavioral Health, Mental Health Services Act and Fresno
County Board of Supervisors will occur on an ongoing basis (Monthly/Bi-
monthly/Quarterly/ Annually).
The Fresno County Office of Education, Special Education Local Plan Area shall provide
annual client statistical reports involving but not limited to reduction in symptoms, disciplinary
referrals, suspensions, and expulsions. FCOE shall gather and track annual outcome
information documenting increased access to mental health treatment.
Funding
Fresno County Office of Education is the Lead Agency and will administer invoicing to Fresno
County on the 101h of each month. The total program cost for FCOE is identified in Exhibit C-
Budget and Budget Narrative and reflects costs and revenue from multiple revenue sources.
The COUNTY's contribution to this program is limited to MHSA funds identified in Exhibit C -
Budget and Narrative. Awarded MHSA funds will be utilized as indicated in the Budget and
Budget Narrative. FCOE will provide for in-kind match in services for the overall program cost
as identified in Exhibit C.
Exhibit B
PROGRAM DEVELOPMENT & IMPLEMENTATION (TIMELINEl:
The vision for the Fresno County Office of Education, SELPA is to implement PSIS in all Fresno
County schools in order to establish an integrated continuum of behavioral and academic
supports for the purpose of increased opportunities for all students. increasing pro-social
behaviors, and increasing achievement. In order to fulfill this vision, the region must first
develop the local capacity and infrastructure to support the schools in developing and
implementing the framework with integrity. Fresno County Office of Education, SELPA is
following evidence-based practices in order to engage in large scale implementation of PSIS.
FCOE will contract with a PSIS Specialist, a trainer from Central Unified School District to write
training materials for all participating cohorts.
During the 2010-2015 school years, five cohorts were trained in the PSIS framework. During
the 2015-2016 academic year, the Fresno County SELPA will begin training a sixth cohort of
regional schools in school-wide positive behavioral supports to meet the need and requests
from school districts.
Exhibit C
Budget & Narrative
MHSA PEl SCHOOL BASED PBIS PROGRAM K-12TH GRADE
FRESNO COUNTY OFFICE OF EDUCATION
PREVENTION AND EARLY INTERVENTION BUDGET
FY 2015-16,2016-17,2017-18,2018-19,2019-20
Budget Categories -Total Budget
Line Item Description FTE% MHSA In-Kind Total
PERSONNEL SALARIES:
0001 Program Manager ( 1) 0.50 50,245 50,245
0002 PBIS Trainers (4) 0.80* 64,890 64,890
0003 Program Secretary 0.50 22,578 22,578
0004 SELPA Administrator 0.02 2,794 2,794
0005 Secretary 0.50 21,474 21,474
0006 Accountant (2) 0.10** 6,227 6,227
*0.20 FTE x 4 Employees = 0.80
**0.05 FTE x 2 Employees = 0.10
SALARY TOTAL 2.42 168,208 168,208
PAYROLL TAXES:
0030 OASDI 3,117 3,117
0031 FICNMEDICARE 2,439 2,439
0032 SUI 84 84
PAYROLL TAX TOTAL 5,640 5,640
EMPLOYEE BENEFITS:
0040 Retirement 22,390 22,390
0041 Workers Compensation 3,448 3,448
0042 Health Insurance (medical, vision, life, dental) 29,618 29,618
EMPLOYEE BENEFITS TOTAL 55,456 55,456
SALARY & BENEFITS GRAND TOTAL 229,304 229,304
FACILITIES/EQUIPMENT EXPENSES·
1010 RenULease Land 12,454 12,454
1011 RenULease Equipment
1012 Utilities
1013 Shelter Maintenance
1014 Irrigation Water
FACILITY/EQUIPMENT TOTAL 12,454 12,454
OPERATING EXPENSES·
1060 Telephone
1061 Answering Service
1062 Postage
1063 Printing/Reproduction
1064 Publications
1065 Legal Notices/Advertising
1066 Office Supplies & Equipment
1067 Household Supplies
1068 Food
1069 Program Supplies -Therapeutic
1070 Program Supplies -Medical
1071 Transportation of Clients
1072 Staff Mileage/vehicle maintenance
1073 Staff Travel (Lodging Out of County)
1074 Release Time (Substitute Teacher) Stipend (please see
narrative line item 1074)
1076 Other-Association for PBIS Support
1077 Other-School-Wide Information System (SWIS)
1079 Other-PBIS Model School
OPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES·
1080 Accounting/Bookkeeping
1081 External Audit
1082 Liability Insurance
1083 Administrative Overhead (6.63%)
1084 Payroll Services
1085 Professional Liability Insurance
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (ConsultanUEtc.):
1090 ConsultanUPSBIS Presenter
1093 Research Activities & Evaluation
1094 Tier I Start-Up Stipend (Cohort Ill)
1095 Text Book Materials & screening tool
1196 Other-Tier II Start-up Stipend (Cohort II)
11,068
11,720
44,160
125
16,500
36,775
120,348
28,998
28,998
20,932
6,129
Exhibit C
Budget & Narrative
15,204
15,204
11,068
11,720
44,160
125
16,500
36,775
120,348
44,202
44,202
20,932
6,129
1197 Other-PBIS Web Page
1198 Other-International Conference on PBIS
1199 Other-Start-up Stipend material & Supplies
1200 Other-Parking Validation
1201 Other-Cohort IV Kick-Off Training
SPECIAL EXPENSE TOTAL
TOTAL PROGRAM EXPENSE
REVENUE·
4000 State AB602 Entitlement
4100 Pre-Referral Federal Mental Health
4200 Other
4300 Other
OTHER REVENUE TOTAL
MHSAFUNDS·
5000 PEl Funds
5100 CSS Funds
MHSA FUNDS TOTAL
3,000
6,996
260,522
1,000
6,000
304,579
Exhibit C
Budget & Narrative
3,000
6,996
260,522
1,000
6,000
0 304,579
466,379 244,508 710,887
45,964 45,964
189,630 189,630
8,914 8,914
244,508 244,508
466,379 466,379
466,379 466,379
TOTAL PROGRAM REVENUE 466,379 244,508 710,887
Budget Narrative
FY 2015-16; 2016-17; 2017-18; 2018-19 and 2019-20
PROGRAM EXPENSES
Exhibit C
Budget & Narrative
Personnel Salaries, Payroll Taxes & Employee Benefits -Line Items 0001-0042
001 through 0042: These amounts reflect staff that is currently
employed by the SELPA with the percentage of FTE reflecting the
staff person's time dedicated to MHSA-PEI activities/duties. The
SELPA Administrator and Accountants positions are paid for with
State AB602 dollars, which is funding for each SELPA based on a rate
per unit of average daily attendance (ADA). PAYROLL TAXES and
EMPLOYEE BENEFITS will be paid for in a like manner. Total in this
area to cover the cost of one Program Managers, four PSIS Trainers,
one SELPA Administrator, one Program Secretary, one Staff
Secretary, and two accountants. The salary amounts indicated in this
section will be paid for in-kind by the SELPA and with State AB602
and Federal Mental Health. No funds from the Mental Health Services
Act will be used to pay for Fresno County SELPA employee costs.
($244,508.00 In-Kind)
Facilities/Equipment Expenses-Line Items 1010-1014
1010 (Venue Cost): Reflects the cost to rent a venue (Golden Palace
@ $1 ,500.00) to provide professional development and to
accommodate the number of multidisciplinary school-wide teams
attending the Positive Behavior Interventions and Supports (Cohort I &
II School Team and Coaches Trainings). ($12,454.00)
Operating Expenses-Line Items 1060-1079
1063 (Printing/Reproduction): Training materials provided for a twelve
days of school team trainings. Estimated cost is $6.00 dollars per
person for materials and folders. Printing and reproduction may also
include sustainability for printing of brochures relating to the PSIS
training. ($11 ,068.00)
1068 (Food): Reflects costs of providing food and beverages for
Coaches and Team trainings throughout the year. ($11, 720.00)
1074 (Release Time Stipend): The cost is to assist the schools in
releasing staff and teachers in order to participate in the training, while
covering the cost for substitute teachers and parents for travel,
childcare, and/or other expenses associated with the training. The
stipend to a school team is broken down in the following manner:
Administrator time ($0.00); School Psychologist time ($0.00); PSIS
Coach per day ($120.00); Teacher Substitute Cost for general
education teacher substitute ($120.00); special education teacher
substitute ($120.00), Para Educator ($60.00), Parent ($200.00), and
student or community agency member stipend ($200.00). Using this
formula, the total stipend for each school team will not exceed $820.00
per team for each day of training. School teams will receive a release
time stipend in the amount of $44,160.00 for day trainings. This
amount has been reduced based on past experiences that school
teams rarely send a full team to the trainings due to personnel being
needed at the school site.
1076 (Association for Positive Behavioral Supports): Cost of
Agency Membership is for the purpose research and Best Practices into
the classroom and whole school level. Research practices will be
incorporated directly into trainings from information provided by the
peer-reviewed journal. In addition, the membership rate will allow the
region to receive the most updated scientific trends related to Positive
Behavior Interventions and Supports. ($125.00)
1077 (School-Wide Information System): The School-Wide
Information System (SWIS) is a web-based system for school teams to
collect and disaggregate behavior data, progress monitor, and improve
decision-making to implement interventions in an efficient manner.
Cost reflects support for the SWIS license fee each academic year for
every PEl Fresno K-12 school. ($16,500.00)
1079 (PBIS Model School): Each year, FCOE will formally recognize
schools that demonstrate implementation and sustainability of the PSIS
process through measurable criteria at the Tier 1/Universal (Bronze),
Tier 2/Secondary (Silver), and Tier 3/Tertiary (Gold) levels. Awards will
be presented based on the Model School Applications, which includes
data collection and site walk-throughs. Schools will be provided a
banner (Bronze, Silver or Gold) to display out in front of their school.
($36, 775.00)
Financial Services Expenses-Line Items 1080-1085
1083 (Administrative Overhead@ 6.63%): Indirect costs are those
costs of general management that are agency-wide. General
management costs consist of expenditures for administrative activities
necessary for the general operation of the County Office of Education
(e.g., accounting, budgeting, payroll preparation, personnel
management, purchasing, and centralized data processing). The
standardized method to recover indirect costs from programs without
having to time-account for the general administrative support provided
to each program is referred to as the indirect cost rate process. The
indirect cost rate process in California is based on the California
Department of Education's (CDE's) federally approved indirect cost
plan for K-12 Local Education Agency's (LEAs), which includes county
offices of education. California's plan includes specific guideline on
Exhibit C
Budget & Narrative
indirect cost components, including the indirect cost pool, base costs,
and the carry-forward adjustment. The United States Department of
Education has approved the fixed-with-carry-forward restricted rate
methodology for calculating indirect cost rates for California
LEAs. CDE has been delegated authority to calculate and approve
indirect cost rates annually for LEAs. $28,998 MHSA funded
($15,204.00 In-Kind)
Special Expenses-Line Items 1090-1201
1090 (Consultant/PBJS Presenter): Reflects the cost to pay
expenses for one (1) consultant for consultation and training. Duties
will include providing school-wide team training on a preventative
framework at the whole school level, providing training to Positive
Behavior Intervention and Supports coaches, and consulting with our
local regional leadership team and local PBIS trainers. ($20,932.00)
1093 (Research Activities/Evaluation): Research activities &
evaluation purposes @ $9,075.50 per semester. ($6, 129.00)
1197 (PBIS Web Page): PBIS webpage modeled after the Florida
Positive Behavior Supports Project website http://flpbs.fmhi.usf.edu/.
This will allow fluid communication and resources to PBIS schools, a
portal for PBIS Coaches and Trainers, and visibility for both Education
and Mental Health for the purpose of integrating preventative services
and reducing stigma and increase access to mental health preventions
and tertiary services. ($3,000.00)
1198 (PBJS Conference): Cost reflect the travel expenses (i.e., flight-
U.S. only, hotel, food, registration fee) for PBIS program staff to attend
conferences and trainings promoting Positive Behavior Interventions,
Mental Health Services or other topics relevant to PBIS. These
conferences include, but are not limited to, the International PBIS
conference, Regional PBIS Conferences, General Education or Special
Education Conferences/Trainings and SWIS Facilitator training.
($6,996.00)
1199 Materials and Supplies Stipend:
Schools will be given funds to implement PBIS. Schools are given funds
for the implementation of Tier I, II, and Ill interventions. ($260,522.00)
(Tier I, Year 1): New schools participating in the PBIS training will
have an opportunity to receive stipends to pay for costs associated with
implementing school-wide prevention interventions and practices. The
proposed start-up fund is $5,000.00 per school. Accountability of
implementation procedures will be measured using the School-wide
Evaluation Tool.
Exhibit C
Budget & Narrative
(Tier II, Year 2): Schools participating in the PSIS training will have an
opportunity to receive stipends to pay for costs associated with
implementing targeted group interventions and practices. Tier II
purchases can include programs such as, Behavior Education Program,
Check-in/Check-Out, Classroom based interventions (Good Behavior
Game), etc. This stipend may also support existing tier II group
interventions for schools (i.e., Prevention and Intervention Program)
attending the PSIS training, as long as the intervention is evidence-
based and matches the criteria set forth in a preventative framework.
Proposed start-up fund is $4,000.00 per school team. Accountability of
implementation procedures will be measured using the School-wide
Evaluation Tool.
(Tier Ill, Year 3): Cost reflects building coordinated tertiary systems of
support in a preventative framework. This may include person-centered
and functional-based materials that can integrate education, mental
health, and community supports. Allocation is $3,000.00 per school
site. Accountability measurement tools will be built in using the
Benchmark Assessment Tool.
(Sustainability Training): Costs reflect the ongoing implementation of
PSIS beyond the initial three year training cycle. Schools who
participate in sustainability trainings will receive funds to support the
long term implementation of PSIS in their school setting.
1200 (Parking Validation): Cost reflects validation for parking for
parents, PSIS coaches, or teachers needing to attend training at the
downtown location. There will be at least 6 Coaches Trainings held at
FCOE with an estimated number of 100 participants at each training.
($1 ,000.00)
1201 (Cohort IV Kick Off Training and Recognition Awards
Ceremony): Cost to host the Cohort IV Kick Off training and Awards
Ceremony. Estimated number of participants is over 600. Cost reflects
the amount for room rental, presenter, materials and supplies required
for this event. ($6,000.00)
Total expenses paid out by MHSA Funds
Total expenses paid out by FCOE In-Kind Match
TOTAL PROGRAM EXPENSE:
Exhibit C
Budget & Narrative
($466,379.00)
($244,508.00)
($71 0,887 .00)
REVENUES
OTHER PROJECTED REVENUE -Line Items 4000-4300
4000 (State AB602 Entitlement): ($45,963.94 In-Kind)
4100 (Federal Mental Health): ($189,629.65 In-Kind)
4200 Other ($8,914.83)
The In-Kind match reflects the expenses paid for by the Fresno
County Special Education Local Plan Area (SELPA). Personnel
salaries & Payroll taxes and employee benefits are also included. In-
Kind facilities and equipment include office space and furniture.
Operating expenses include costs for telephone use and postage,
office supplies, household items, and payment for mileage. A portion
of the Administrative Overhead is paid In-Kind for Financial Services.
MHSA FUNDS-Line Items 5000-5100
5000 PEl Funds ($466,379.00)
Total amount of MHSA Funds requested for provision of services
covered by the Agreement resulting from this RFP.
TOTAL PROGRAM REVENUES:
Exhibit C
Budget & Narrative
($466,379.00)
($710,887.00)
EXHIBIT-D
,<1'?i,0.,:;~:,~~v:tHREE~V;e~Ji!lP:t?A~f!~{tiii!J:«@"t~J~ik¥.ii_~r{o·t31~~:&~1~g:O.'j(~~~~N~IR.~BP'Rfit~~~i:~5:;~e:t;:\i~i£1'~'~@5J~fl1)t~V~;(,~'IJ%ii.(f;i~}:;.:;;;,~;;~i.;,Eil{;:tif::i?#:t;;;r'~t.;~;~~;,}'~~:·;
Estimated/Actual Population Served
·.·iProgram!M"ork!I{Ian~~:eii~veJJ,tionX&:\~a~Iy~Ilile~WentHi#~~~,~\iijf;~~;'li~J~
4J?rogramf\WorRfetamNam~'i:ff:IDitPEis4::;:;:;;'!~~%t;ro:iN·z\~f.~1I~::x~~~tE;!\\iit{ill~7fi%ij
::f:isca:f'fl,eari~t2o1rs~f6'\{:;,?:'?'Iii~i~~\~~;~,,;:r,¥~~i{~·J~J:;;s:~~~~fl~~t'.'tr§ii!~~*~'i;~~~g;~~•~f(~~;·~~~~·G;
Exhibit· E
State Quarterly Progress Report Instructions
Current Quarterly Progress Report Process Overview
Page 1 of 3
Current Regulations:
Title 9. Division 1. Chapter 14, Article 5: Quarterly Progress Reports must be submitted
to the State Department of Mental Health no later than 60 days following the end of
each reporting quarter and are compiled by service category for each approved
program and/or service. The following information must be included in the Quarterly
Progress Report:
• The targeted number of individuals or families to be served in each reporting
quarter by each program/service during the quarter
• The total number of individuals or families actually served in each reporting
quarter by each program/service during the quarter
• The final Quarterly Progress Report must include the total number of
unduplicated individuals or families served by each program/service during the
fiscal year
Following is a review of how to calculate individuals served within each service category
(Full Service Partnerships, System Development and Outreach and Engagement).
Quarterly Counts:
The quarterly count is un-duplicative within quarters but is duplicative between quarters.
The number of actual individuals served equals: the total number of individuals or
families enrolled in the program on the first day of each quarter plus any individuals or
families newly enrolled throughout the quarter.
Example:
Program Q1 Q2 Q3 Q4
Currently enrolled on first day of quarter 10 20 20 26
Newly Enrolled 10 5 7 5
Actually Served 20 25 27 31
Dis-enrolled 0 (5) (1) 0
Explanation:
Q1: At the beginning of Quarter 1, 1 0 people were enrolled and 10 people were newly
enrolled throughout the quarter, so the total actual served for Quarter 1 would
equal 20 (10 + 10 = 20).
Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more
people were newly enrolled, so the total actual served would equal25 (20 + 5 =
25).
Q3:
Exhibit-E
State Quarterly Progress Report Instructions
Page 2 of 3
At the beginning of Quarter 3, 20 people were currently enrolled and 7 more
people were newly enrolled throughout the quarter, so the total actual served
would equal 27 (20 + 7 = 27). (Five people dis-enrolled the previous quarter, so on
the first day of Quarter 3, 20 people were currently enrolled.)
Q4: At the beginning of Quarter 4, 26 people were currently enrolled because one had
dis-enrolled during Quarter 3, but 5 had been newly enrolled so the total actual
served of 31 (26 + 5 = 27)
Quarterly targets: The quarterly target is an estimate of the total number of individuals
you expect to serve for that quarter. Targeted counts should follow the same strategy as
for actual counts described above.
Unduplicated Annual Counts:
The unduplicated annual count: Equals the total number of people served for the entire
year.
Example:
Actual Served
Dis-enrolled
Q1: At the beginning of Quarter 1, 10 people were enrolled and 10 people were newly
enrolled throughout the quarter, so the total unduplicated for Quarter 1 would
equal20 (10 + 10 = 20).
Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more
people were newly enrolled, so the total unduplicated for quarter 2 would be 5.
Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more
people were newly enrolled throughout the quarter, so the total unduplicated for
quarter 3 would be 7.
Q4: At the beginning of Quarter 4, 26 people were currently enrolled and 5 had been
newly enrolled so the total unduplicated for quarter 4 would be 5.
Total Unduplicated Annual Actual Served: 20 + 5 + 7 + 5 = 37
Total Unduplicated Annual Targets: The unduplicated annual target is an estimate of
the total number of unduplicated individuals you expect to serve annually,
Exhibit-E
State Quarterly Progress Report Instructions
Page 3 of 3
Options for Improving the
MHSA Quarterly Progress Reporting Process
Outreach and Engagement:
There are many different methods of providing outreach and engagement services.
Some services are offered in a group or community wide forum and sometimes services
are offered individually. Ideally, it would be helpful to have a combination of service
based and individual level data collection that is submitted on a quarterly basis.
Potential Methods for reporting counts in these service categories:
Categories could be created based on the nature of the services provided. There are
two very broad categories of services and they could be reported differently based on
these categories: For instance:
Community Forum Outreach and Engagement Activities:
When conducting a community forum activity such as a county-wide presentation to
a group of people about a mental health issue, a count of the number of
presentations and the number of individuals that attended could be submitted.
Some indication of the purpose of each event would also be helpful. For instance,
broad categories such as education, workforce development, stigma reduction or
outreach to engage in services could be indicated.
Individual Outreach and Engagement Services:
When conducting outreach and engagement services to individuals, you may have
multiple contacts with an individual prior to engaging them into services. Counting
the number of contacts rather than the number of individuals would provide more
accurate information regarding individual services.
In addition, some demographic information regarding the individuals receiving
services within these categories would be helpful including gender, age and
race/ethnicity. In addition, information regarding the number of face-to-face
contacts vs. phone contacts would also be useful.
System Development:
There are many types of services provided through this category. Some services maybe
offered in a group or community wide forum and some services may be offered to
individuals and families. In addition, some services center around linkage with other
community based organizations. Should the services be categorized similar to what
has been proposed for Outreach and Engagement or should there be different
categories for System Development services?
STATE MENTAL HEALTH REQUIREMENTS
Exhibit F
Page I of2
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 ofthe
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
0374 fdbh
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit F
Page 2 of2
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY's Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights
0374 fdbh
Exhibit G
Page 1 of3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTORCODEOFCONDUCTANDETHICS
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 ofthis 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 G
Page2 of3
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.
Fresno countv Mental Health compliance Pragram
Contractor Acknowledgment and Agreement
Exhibit G
Page3 of3
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 0 Psychologist 0 LCSW 0 LMFT
Signature: ____________________________ ___ Date : _/ __ /_
For Group or Organizational Providers
Group/Org. Name (print): --------------------
Employee Name (print):-----------------
Discipline: 0 Psychiatrist 0 Psychologist 0 LCSW 0 LMFT
0 Other: ________________ _
Job Title (if different from Discipline):------------
Signature: ______________ Date: __ /_/ __
Exhibit H
1 of2
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 H
2 of2
(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)
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. ldenti in Information
Name of entity D/B/A
Address (nurmer, street) City
CLIAnumber Taxpayer ID number (EIN) Telephone nurrber
ZIP code
Exhibit I
Page 1 of2
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
D D
D D
D D
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: D Sole proprietorship o Partnership o Corporation
o Unincorporated Associations D 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 .......................................................................................................... . 0 0
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? ...................................................... . lfyes,when? ______________________________________ ___
C. Do you anticipate filing for bankruptcy within the year? ............................................................................... .
lfyes,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 (nurrber, name) City State
B. If the answer to question VI I.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (nurrber, name) City State
ZIP code
ZIP code
Exhibit I
Page 2 of2
YES NO
a a
a a
a a
a a
a a
a a
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
SELF-DEAUNG TRANSACTION DISCLOSURE FORM
Exhibit J
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 ofthe following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature ofthe 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: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
Exhibit J
Page 2 of2
(4) Explain why this self-dealing transaction Is consistent with the requirements of Corporations Code 5233 (a)
(5} Authorized Signature
Signature: I Date:
I
Fresno County Mental Health Plan
Grievances
Exhibit K
Page 1 of 2
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers' offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit K
Page 2 of 2
Informal provider problem resolution process-the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process -the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider's claim to the MHP.
Pavment authorization issues-the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider's claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints-if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
FRESNO COUNTY MENTAL HEALTH PLAN
GRIEVANCES AND 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.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent -within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) -------Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who 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 D inconsequential D consequential D death D not applicable 0 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