HomeMy WebLinkAbout32141Agreement No. 15-256
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this /lifl-. day of \J lt,J\..e '2015,
3 by and between the COUNTY OF FRESNO, a Political Subdivision ofthe State of California,
4 hereinafter referred to as "COUNTY", and each CONTRACTOR(S) listed in Exhibit A, "List of
5 Contractors", attached hereto and by this reference incorporated herein, collectively hereinafter
6 referred to as CONTRACTOR(S)", and such additional CONTRACTOR(S) as may, from time to time
7 during the term ofthis Agreement, be added by COUNTY with the Department of Behavioral Health
8 (DBH) Director, or designee, approval. References in this Agreement to "party" or "parties" shall be
9 understood to refer to COUNTY and each CONTRACTOR, unless otherwise specified.
10 W I T N E S S E T H:
11 WHEREAS, COUNTY, through its Department ofBehavioral Health (DBH), has a need for
12 transportation services to be provided on a twenty-four (24) hours per day, seven (7) days a week basis
13 to transport mental health clients as specified in this Agreement, as well as additional services
14 required by COUNTY as stated herein; and
15 WHEREAS, CONTRACTOR(S) are qualified and willing to provide services pursuant to the
16 terms and conditions ofthis Agreement; and
17 NOW, THEREFORE, in consideration oftheir mutual covenants and conditions, the parties hereto
18 agree as follows:
19 1. SERVICES
20 A. CONTRACTOR(S) shall perform all services and fulfill all responsibilities
21 identified in Exhibit B, Scope of Work, attached hereto and by this reference incorporated herein, as
22 well as COUNTY's RFQ No. 070-5331, dated January 28, 2015 and CONTRACTOR(S) responses to
2 3 said RFQ No. 070-5331, all incorporated by reference and herein made part of this Agreement. In the
2 4 event of any inconsistency among these documents the inconsistency shall be resolved by giving
2 5 precedence to the following order: I) to this Agreement including all Exhibits, and all amendments
2 6 thereto, to CONTRACTOR(S) Responses to the RFQ No. 070-5331. A copy of COUNTY's RFQ No.
2 7 070-5331, and CONTRACTOR(S) responses shall be retained and made available during the term of
2 8 this Agreement by COUNTY's DBH Contracted Services Division.
- 1 -COUNTY OF FRESNO
Fresno, CA
1 2.TERM
2 This Agreement shall become effective on the 1st day of July,2015 and shall terminate
3 on the 30th day of June,2018.
4 Effective July1st,2018,this Agreement,subject to satisfactory outcomes performance
5 and subject to available funding each year,shall be extended for two (2)additional twelve (12)month
6 periods upon the same terms and conditions herein set forth,unless written notice of non-renewal is
7 given by COUNTY or CONTRACTOR(S)or COUNTY'S DBH Director or designee,not later than
8 sixty (60)daysprior to the close of the currentAgreementterm.
9 3.TERMINATION
10 A.Non-Allocation of Funds - The terms of this Agreement, and the services to be
11 provided thereunder,is contingent onthe approval of funds bythe appropriating government agency.
12 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
13 terminated atany time by giving CONTRACTOR(S)sixty (60)days advance written notice.
14 B. Breach of Contract - COUNTYmay immediatelysuspend or terminatethis
15 Agreement in whole orin part,where inthe determination of COUNTY there is:
16 1)An illegal or improper use of funds;
17 2) A failureto complywith any term of this Agreement;
18 3) A substantiallyincorrector incompletereport submittedto COUNTY;
19 4) Improperly performed service.
20 Innoeventshallany payment by COUNTY constitute awaiverby COUNTY ofany
21 breach of this Agreement orany default which may then exist on the partof CONTRACTOR(S).
22 Neither shall such payment impair or prejudice any remedy available to COUNTY with respect tothe
23 breachor default. The COUNTY shall have the right to demand of the CONTRACTOR(S)the
24 repayment to the COUNTY of any funds disbursed to CONTRACTOR(S)under this Agreement,
25 which inthe judgment of COUNTY were not expended in accordance with the terms ofthis
26 Agreement.The CONTRACTOR(S)shall promptly refund any such funds upon demand.
27 C. Without Cause - Under circumstances other than those set forth above, this
28 Agreement may be terminated by COUNTY or CONTRACTOR(S)upon the giving of sixty (60)days
COUNTY OF FRESNO
Fresno,CA
1 advance written notice of an intention to terminate.
2 4.COMPENSATION
3 COUNTY agrees to pay CONTRACTOR(S)and CONTRACTOR(S)agree to receive
4 compensation in accordance with the rates set forth within each CONTRACTORS'respective
5 Quotation Schedule attached hereto as Exhibit C-1,C-2,C-3 and incorporated herein by this reference.
6 In no event shall the annual contract maximum exceed One Hundred Thousand and No/100 Dollars
7 ($100,000.00)for each twelve (12)month period of this Agreement forall CONTRACTOR(S).Inno
8 event shall services performed under this Agreement bein excess of Five Hundred Thousand and
9 No/100 Dollars ($500,000.00)during thetermofthis Agreement forall CONTRACTOR(S).
1o Payment shall be made upon certification orotherproof satisfactory to COUNTY'S DBH
11 that services have actually been performed by CONTRACTOR(S)as specified inthis Agreement.
12 A. Itis understoodthatall expenses incidental to CONTRACTOR(S)'s performance
13 of services under this Agreement shall be borne by CONTRACTOR(S).If CONTRACTOR(S)fails
14 to comply with any provision of this Agreement,COUNTY shall be relieved of its obligation for
15 further compensation.
16 B.Payments shall be made by COUNTY to CONTRACTOR(S)in arrears,for
17 services provided during the preceding month,within forty-five (45)days after the date of receipt and
18 approval by COUNTY of the monthly invoicing as described in Section Five (5)herein.Payments
19 shall be made after receipt and verification of actual expenditures incurred by CONTRACTOR(S),as
20 identified in Exhibit C,-l,C-2,C-3 andshallbe documented to COUNTY ona monthly basisbythe
21 tenth (10th)of the month following the month of said expenditures.
22 C. COUNTY shall not be obligatedto make any payments under this
23 Agreement if the request for payment is received by COUNTY more than sixty (60)days after this
24 Agreementhas terminated or expired.
25 All finalclaims,including actualcostper service,and/or anyfinalbudget
26 modification requests shall be submitted by CONTRACTOR(S)within sixty (60)days following the
27 final month of service for which payment is claimed.No action shall be taken by COUNTY on claims
28 submitted beyond the sixty (60)day closeout period.Any compensation which is not expended by
COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR(S)pursuant tothetermsand conditions ofthis Agreement shall automatically revert
2 to COUNTY.
3 D. It is understoodby CONTRACTOR(S)and COUNTYthat this Agreementis
4 funded with mental health funds to serve individuals who are seriously mentally ill (SMI) or have
5 serious emotional disturbances (SED).
6 E. In the event that fundingfor these services is delayedby the State Controller,
7 COUNTY may defer payments to CONTRACTOR(S).The amount ofthe deferred payment shall not
8 exceed the amount of funding delayed bythe State Controller to COUNTY.The period of time ofthe
9 deferral by COUNTY shall not exceed the period of time ofthe State Controller's delay of payment to
10 COUNTY plus forty-five (45) days.
11 5.INVOICING
12 A.CONTRACTOR(S)shall invoice COUNTY in arrears by the tenth (10th)day of
13 each month forthepriormonth's actual services rendered and submit invoices via email to DBH-
14 Invoices@co.fresno.ca.us.After CONTRACTOR(S)renders services to referred clients,
15 CONTRACTOR(S)will invoice COUNTY for payment and certify the expenditure by listing dates
16 and locations of services on each monthly invoice.
17 B. At the discretion of COUNTY's DBH Director,or designee,if an invoice is
18 incorrect or is otherwise notinproper form or substance,COUNTY'S DBH Director,or designee,
19 shall have therightto withhold payment asto only that portion ofthe invoice thatis incorrect or
20 improper after five (5)days prior notice to CONTRACTOR(S).CONTRACTOR(S)agrees to
21 continue to provide services for a period of ninety (90)days after notification ofan incorrect or
22 improper invoice.If after the ninety (90)day period,the invoice(s)is still not corrected to
23 COUNTYDBH's satisfaction,COUNTY'S DBH Director,or designee,may elect to terminatethis
24 Agreement,pursuant to the termination provisions stated in Section Three (3)of this Agreement.In
25 addition,for invoices received ninety (90)days afterthe expiration of each term ofthis Agreement
26 or termination of this Agreement,atthe discretion of COUNTY'S DBH Director,or designee,
27 COUNTY'S DBH shallhavetherighttodeny payment ofany additional invoices received.
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- 4 -COUNTY OF FRESNO
Fresno,CA
1 C.Monthly invoices shall include a client roster,identifying the number of
2 transportation requests received,client names,dates and times of service,delivery and drop off
3 locations, and any incomplete transportation requests.
4 D.CONTRACTOR(S)shall remit to COUNTYon a quarterlybasis, a summary
5 report of total operational costs and volume of service unit to report the actual costs per unit
6 compared to the negotiated rate,as identified in Exhibit C-1,C-2, C-3,to report interim cost per
7 unit.The quarterly reports will be used by COUNTY to ensure compliance with federal
8 reimbursements certified public expenditures.
9 E.CONTRACTOR(S)mustreportall thirdpartycollectionsfromother funding
10 sources such as Medicare,private insurance,client privatepayorany other third party.COUNTY
11 expects the invoice for reimbursement to equal the amount due CONTRACTOR(S)less any funding
12 sources not eligible for federal reimbursement.
13 F.CONTRACTOR(S)willremitannuallywithinninety(90)days from June30,a
14 schedule to provide the required information on published charges (PC)for all authorized services.
15 The published charge listing will serve as a source document to determine the CONTRACTOR(S)'s
16 usual and customary charge prevalent in the public mental health sector that is used to bill the
17 general public,insurers or other non-Media-Cal third party payers during the course of business
18 operations.
19 G.CONTRACTOR(S)shall submitmonthlystaffingreports that identifyall direct
20 service and support staff,applicable licensure/certifications,and full time hours worked tobe used
21 asa tracking tool to determine if CONTRACTOR(S)'program is staffed according to the
22 Agreement requirements.
23 H.CONTRACTOR(S)mustmaintainsuch financial recordsfor a periodof seven
24 (7)years or until any dispute,audit or inspection is resolved,whichever is later.CONTRACTOR(S)
25 will be responsible for any disallowances related to inadequate documentation.
2 6 6.INDEPENDENT CONTRACTOR(S)
27 In performance of the work,duties,and obligations assumed by CONTRACTOR(S)
28 under this Agreement,it is mutually understood and agreed that CONTRACTOR(S),including any
COUNTY OF FRESNO
Fresno,CA
1 andall of CONTRACTOR(S)' officers,agents,and employeeswill at all times be acting and
2 performing as independent contractors,and shall act inan independent capacity and not asan officer,
3 agent,servant,employee,joint venture,partner,or associate of COUNTY.Furthermore,COUNTY
4 shall have norightto control or supervise or direct the manner or method by which
5 CONTRACTOR(S)shall perform its work and function.However,COUNTY shall retain the right to
6 administer this Agreement soasto verify that CONTRACTOR(S)is performing their obligations in
7 accordance with the terms and conditions thereof.CONTRACTOR(S)and COUNTY shall comply
8 with all applicable provisions of law and the rules and regulations,if any,of governmental authorities
9 having jurisdiction over matters which are directly or indirectly the subject of this Agreement.
1o Because of itsstatusasan independent contractor,CONTRACTOR shallhave absolutely
11 no right to employment rights and benefits available to COUNTY employees.CONTRACTOR(S)
12 shall be solely liable and responsible for providing to,oron behalf of,its employees all legally-
13 required employee benefits.In addition,CONTRACTOR(S)shall be solely responsible and save
14 COUNTY harmless fromall matters relating to payment of CONTRACTOR(S)'employees,including
15 compliance with Social Security,withholding,and all other regulations governing such matters.Itis
16 acknowledged that during the term of this Agreement,CONTRACTOR(S)may be providing services
17 to others unrelated to COUNTY or to this Agreement.
18 7.MODIFICATION
19 Any matters of this Agreement may be modified from time to time by the written consent
20 ofallthe parties without,inany way,affecting the remainder.
21 Additions to ExhibitA, "List of Contractors",maybemadewith writtenapprovalof
22 COUNTY'S DBH Director,or designee,as definedfurtherin SectionEight(8) ofthis Agreement.
23 Changes to the rates identified in Exhibit C-1,C-2,C-3 "Quotation Schedule",may be made with
24 written approval of COUNTY'S DBH Director,or designee and CONTRACTOR(s).
25 8.ADDITIONS/DELETIONS OF CONTRACTOR(S)
2 6 COUNTY'S DBH Director,or designee,reserves therightatanytime during the term of
27 this Agreement to add CONTRACTOR(s)to Exhibit A,"List of Contractors".Itis understood any
28 such additions willnot affect compensation paid tothe other CONTRACTOR(s)under this Agreement.
COUNTY OF FRESNO
Fresno,CA
1 These same provisions shall apply to the deletion of any CONTRACTOR(s)contained in Exhibit A,
2 except that deletions shall be made by mutual written consent between COUNTY and the specific
3 CONTRACTOR(s)tobe deleted or shall bein accordance with Section Five (5)of this Agreement.
4 Additions to Exhibit A,"Listof Contractors",maybemadewithwritten approval of
5 COUNTY'S DBH Director,or designee,upon COUNTY'S DBH Director,or designee,having received
6 and approved submitted proposals for additional CONTRACTOR(S).Proposals for the inclusion of
7 CONTRACTOR(S)must be prepared and submitted in accordance with RFQ No.070-05331 to:
8 County of Fresno,Department of Behavioral Health,Contracted Services Division,3133 N.Millbrook
9 Avenue,Fresno,CA 93703.
10
11 9.NON-ASSIGNMENT
12 No party shall assign,transfer or subcontract this Agreement nor their rights or duties
13 under this Agreement without the prior written consent of COUNTY and CONTRACTOR(S).
14 10.HOLD-HARMLESS
15 CONTRACTOR(S)agreesto indemnify,save,hold harmless,and at COUNTY'S request,
16 defend COUNTY,its officers,agents and employees from anyandall costs and expenses,including
17 attorney fees and court costs,damages,liabilities,claims and losses occurring or resulting to
18 COUNTY in connection withthe performance,or failure to perform,by CONTRACTOR(S),its
19 officers,agents or employees under this Agreement,and from any and all costs and expenses,
20 including attorney fees and court costs,damages,liabilities,claims and losses occurring or resulting to
21 any person,firm or corporation who may be injured or damaged by the performance,or failure to
22 perform,of CONTRACTOR(S),their officers,agents or employees under this Agreement.
23 CONTRACTOR(S)agrees to indemnify COUNTY for Federal and/or State of California
24 audit exceptions resulting from noncompliance herein on the part of CONTRACTOR(S).
25 11.INSURANCE
26 Without limiting COUNTY'S right to obtain indemnification from CONTRACTOR(S)or
27 any third parties,CONTRACTOR(S),at its sole expense,shall maintain in full force and effect the
28 following insurance policies throughout thetermofthis Agreement:
COUNTY OF FRESNO
Fresno,CA
1 A.Commercial General Liability
2 Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000)per occurrence andan annual aggregate of Two Million
Dollars ($2,000,000).This policy shall be issued onaper 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
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6 nature of the Agreement.
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B.Automobile Liability
9 Comprehensive Automobile Liability Insurance with limits for bodily injury of
not lessthanTwo Hundred FiftyThousandDollars ($250,000)perperson,Five
10 HundredThousand Dollars ($500,000)per accident and for propertydamages of
not less than Fifty Thousand Dollars ($50,000),or such coverage with a combined
single limit of Five Hundred Thousand Dollars ($500,000).Coverage should
12 includeowned andnon-ownedvehiclesused in connectionwith this Agreement.
11
13 C. Real And Personal Property
14 CONTRACTOR(S)shall maintain apolicyof insurance forallrisk personal
15 property coverage which shall be endorsed naming the County of Fresno asan
additional loss payee.The personal property coverage shall beinan amount that
16 will cover the total of the County purchased and owned property,ata minimum,
17 as discussed in Section Twenty-One (21)ofthis Agreement.
18 All Risk Property Insurance
19 CONTRACTOR(S)will provide property coverage for the full replacement value
ofthe County's Personal Property inthe possession of CONTRACTOR(S)and/or
usedin the executionofthis agreement.Countywill be identified onan
21 appropriate certificate of insurance as the certificate holder and will be named as
an AdditionalLoss Payee on the PropertyInsurancePolicy.
23 D.Professional Liability
24 If CONTRACTOR(S)employslicensed professional staff(e.g. Ph.D.,R.N.,
L.C.S.W.,L.M.F.T.)in providing services,Professional Liability Insurance with
25 limits of not less than One Million Dollars ($1,000,000)per occurrence,Three
2 6 Million Dollars ($3,000,000)annual aggregate.CONTRACTOR(S)agrees that it
shall maintain,atits sole expense,in full force and effect fora period of three (3)
27 years following the termination of this Agreement,one or more policies of
professional liability insurance with limits of coverage as specified herein.
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COUNTY OF FRESNO
Fresno,CA
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Worker's Compensation
2 A policy of Worker'sCompensationInsuranceas may be required by the
California Labor Code.
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F.Child Abuse/Molestation and Social Services Coverage
5 CONTRACTOR(S) shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
6 coverage or have a specific endorsement on their General Commercial liability
policy covering ChildAbuse/Molestationand Social ServicesLiability. The
policy limits for thesepolicies shall be $1,000,000per occurrencewith
$2,000,000 annual aggregate. The policies are to be on a per occurrence basis.
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CONTRACTOR(S)shall obtain endorsements to the Commercial General Liability
insurancenaming the County of Fresno,its officers,agents, and employees,individuallyand
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned.Such coverage for additional insuredshallapply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
excess onlyandnot contributingwith insurance providedunder CONTRACTOR(S)'S policies herein.
This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance
written notice given to COUNTY.
Within thirty (30) days from the date CONTRACTOR(S) signs this Agreement,
CONTRACTOR(S)shallprovide certificates of insurance and endorsements as statedaboveforall of
the foregoing policies,as required herein,tothe County of Fresno,Department of Behavioral Health,
3133 N. Millbrook Ave, Fresno, California, 93703, Attention: Contracts Section, stating that such
insurance coverages havebeen obtained andareinfull force;thattheCountyof Fresno,its officers,
agents and employees will notbe responsible for any premiums on the policies;that such Commercial
General Liability insurance names the County of Fresno,its officers,agents and employees,
individually and collectively,as additional insured,butonly insofar asthe operations under this
Agreement are concerned;that such coverage for additional insured shall apply as primary insurance
and any other insurance,or self-insurance,maintained by COUNTY,its officers,agents and
employees,shall be excess onlyandnot contributing with insurance provided under
- 9 -COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR(S)'policies herein;and thatthis insurance shall notbe cancelled or changed without
2 a minimum ofthirty(30)days advance,writtennoticegivento COUNTY.
3 In the event CONTRACTOR(S) fails to keep in effect at all times insurance coverage as
4 herein provided,COUNTY may,in addition to other remedies it may have,suspend or terminate this
5 Agreementupon the occurrence of such event.
6 All policies shall be with admitted insurers licensed todo business in the State of
7 California.Insurance purchased shall be from companies possessing a current A.M.Best,Inc.rating of
8 A FSC VII or better.
9 12.LICENSES/CERTIFICATES
1o Throughout each term of this Agreement,CONTRACTOR(S)and CONTRACTOR(S)'
11 staff shall maintain all necessary licenses,permits,approvals,certificates,waivers and exemptions
12 necessary for the provision of the services hereunder and required by the laws and regulations of the
13 United States of America, State of California, the County of Fresno, and any other applicable
14 governmental agencies.CONTRACTOR(S)shall notify COUNTY immediately in writing of its
15 inability to obtain or maintain such licenses,permits,approvals,certificates,waivers and exemptions
16 irrespective of the pendency of any appeal related thereto.Additionally,CONTRACTOR(S)and
17 CONTRACTOR(S)'staff shall comply withall applicable laws,rules or regulations,asmay now exist
18 or be hereafter changed.
19 13.RECORDS
20 CONTRACTOR(S)shall maintain records documenting thenumberof transportation
21 requests received,delivery and drop offof clients,and any incomplete transports.This documentation
22 shallindicatethe client's name, time and date of said service,pick up and drop off locations,mileage,
23 and any incomplete transport requests.This information shall be submitted ina standardized format
24 approved by the COUNTY.
25 CONTRACTOR(S)shall maintain all above-mentioned records and submit them,when
26 requested by DBH.The client records shall be considered property of the COUNTY and all client
27 recordsshallbe returned upon expirationor termination of this Agreement.
28 14.REPORTS
10 -COUNTY OF FRESNO
Fresno,CA
1 A.CONTRACTOR(S),or any Delegateperformingthe covenants of
2 CONTRACTOR(S)pursuant to thetermsofthis Agreement,shall provide at COUNTY'S request,any
3 required reportsto COUNTYwhichmayinclude performance outcome reports.
4 B. Monthly Reports -CONTRACTOR(S)shall submit to COUNTY'S DBH by the
5 tenth (10th)of each month all monthly activity and budget reports for the preceding month.In addition,
6 CONTRACTOR(S)shallalso furnish to COUNTY such statements,records,reports,data,andother
7 information as COUNTY may request pertaining to matters covered bythis Agreement.Inthe event
8 that CONTRACTOR(S)fails to provide such reports orother information required hereunder,it shall
9 be deemed sufficient cause for COUNTY to withhold monthly payments until there is compliance. In
10 addition,CONTRACTOR(S)shall provide written notification and explanation to COUNTY within
11 five (5)days of any funds received from another source to conduct the same services covered by this
12 Agreement.
13 C. Annual Reports -CONTRACTOR(S)shall maintain the number of client
14 transports provided,type of transport vehicle used,total miles traveled monthly,and number of
15 additional attendants by completing Annual Services Analysis Report as identified in Exhibit D,
16 attached hereto and by this reference incorporated herein.
17
18 15.MONITORING
19 CONTRACTOR(S)agrees toextendto COUNTY'S staff,COUNTY'S DBH Director and
20 the State Department of Health Care Services,or their designees,the right to review and monitor
21 records,programs or procedures,at any time,in regard to clients,as well as the overall operation of
22 CONTRACTOR(S)'s programs,in order to ensure compliance with the terms and conditions of this
23 Agreement.
24 16.REFERENCES TO LAWS AND RULES
25 Inthe event any law,regulation,or policy referred tointhis Agreement is amended
26 during the term thereof,the parties hereto agree to comply with the amended provision as of the
2 7 effective date of such amendment.
28 17.COMPLIANCE WITH STATE REQUIREMENTS
11 -COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR(S)recognizes that COUNTY operates its mental health programs under
2 an agreement with the State of California Department of Health Care Services, and that under said
3 agreement the State imposes certain requirements on COUNTY and its subcontractor(s).
4 CONTRACTOR(S)shall adhere to all State requirements,including those identified in Exhibit E
5 "State Mental Health Requirements",attached hereto and by this reference incorporated herein and
6 made part of this Agreement.
7 18.CONFIDENTIALITY
8 All services performed by CONTRACTOR(S)under this Agreement shall be in strict
9 conformance with all applicable Federal, State of California and/or local laws and regulations relating
10 to confidentiality.
11 19.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
12 A. The parties to this Agreement shall be in strict conformance with all applicable
13 Federal and State of California laws and regulations, including but not limited to Sections 5328,
14 10850,and 14100.2 etseq.of the Welfare and Institutions Code, Sections 2.1 and 431.300 etseq.of
15 Title 42, Code of Federal Regulations (CFR), Section 56 etseq.of the California Civil Code, Sections
16 11977 and 11812 of Title 22 of the California Code of Regulations,and the Health Insurance
17 Portability and Accountability Act (HIPAA),including but not limited to Section 1320 D etseq.of
18 Title 42, United States Code (USC) and its implementing regulations, including, but not limited to
19 Title 45, CFR,Sections 142, 160, 162, and 164, and The Health Information Technology for
20 Economic and Clinical Health Act (HITECH) regarding the confidentiality and security of patient
21 information.
22 Exceptas otherwiseprovided in this Agreement,CONTRACTOR(S),as a Business
23 Associateof COUNTY,may use or discloseProtectedHealth Information (PHI) to perform functions,
24 activities or services for or on behalf of COUNTY,as specified in this Agreement,provided that such
25 use or disclosure shall not violate the HIPAA, USC 1320d etseq.The uses and disclosures of PHI
26 maynotbe moreexpansivethanthose applicable to COUNTY,asthe "CoveredEntity"underthe
27 HIPAAPrivacyRule (45 CFR 164.500 etseq),exceptas authorized for management,administrative
28 or legal responsibilities of the Business Associate.
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Fresno,CA
1 B.CONTRACTOR(S)shall protect,from unauthorized access,use,or disclosure of
2 names andother identifying information concerning persons receiving services pursuant tothis
3 Agreement,except where permitted in order to carry out data aggregation purposes for health care
4 operations [45 CFR Sections 164.504 (e)(2)(i),164.504 (3)(2)(ii)(A),and 164.504 (e)(4)(i)]-This
5 pertains to any and all persons receiving services pursuant toa COUNTY funded program.
6 CONTRACTOR(S)shall not use such identifying information for any purpose other than carrying out
7 CONTRACTOR(S)'obligations under this Agreement.
8 C.CONTRACTOR(S)shallnotdiscloseanysuch identifying information toany
9 person or entity,except as otherwise specifically permitted by this Agreement,authorized by law,or
10 authorized by the client/patient.
11 D.For purposes ofthe above sections,identifying information shall include,butnot
12 be limited to name,identifying number,symbol,or other identifying particular assigned tothe
13 individual,such as finger or voice print, or a photograph.
14 E.CONTRACTOR(S)shallprovideaccess,at therequestof COUNTY,andinthe
15 time and manner designated by COUNTY,to PHI ina designated record set (as defined in 45 CFR
16 Section 164.501),toan individual orto COUNTY in order to meet the requirements of 45 CFR
17 Sectionl64.524 regarding accessby individuals to theirPHI.
18 CONTRACTOR(S)shall make any amendment(s)toPHIina designated record setatthe
19 request of COUNTY,and in the time and manner designated by COUNTY in accordance with 45 CFR
20 Section 164.526.
21 CONTRACTOR(S)shall provide to COUNTY ortoan individual,ina timeand manner
22 designated by COUNTY,information collected in accordance with 45 CFR Section 164.528,to permit
23 COUNTY to respond toa request by the individual for an accounting of disclosures of PHI in
24 accordance with 45 CFR Section 164.528.
25 F.CONTRACTOR(S)shallreportto COUNTY,in writing,any knowledge or
26 reasonable beliefthattherehasbeen unauthorized access,viewing,use,disclosure,or breach of
27 Protected Information not permitted by this Agreement,and any breach of unsecured PHI of which it
28 becomes aware,immediately and without reasonable delay and in no case later than two (2)business
13 -COUNTY OF FRESNO
Fresno,CA
1 days of discovery.Immediate notification shall be made to COUNTY'S Information Security Officer
2 and Privacy Officerand COUNTY'S DBH HIPAA Representative,withintwo(2)business daysof
3 discovery.The notification shall include,tothe extent possible,the identification of each individual
4 whoseunsecuredPHI has been, or is reasonablybelieved to havebeen, accessed, acquired,used,
5 disclosed, or breached.CONTRACTOR(S)shall take prompt corrective action to cure any
6 deficiencies andanyaction pertaining tosuch unauthorized disclosure required by applicable Federal
7 andStateLawsand regulations.CONTRACTOR(S)shall investigate suchbreachandis responsible
forall notifications required by lawand regulation or deemed necessary by COUNTY andshall
9 provide a written report ofthe investigation and reporting required to COUNTY'S Information
10 Security Officer and Privacy Officer and COUNTY'S DBH HIPAA Representative.This written
11 investigation and description ofany reporting necessary shall be postmarked within the thirty (30)
12 working daysofthe discoveryofthebreachto the addresses below:
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County of Fresno County of Fresno Countyof Fresno
Department of Behavioral Health Dept.of Public Health Information Technology Services
15 HIPAA Representative Privacy Officer Information Security Officer
(559)453-4809 (559)445-3249 (559)600-5800
16 4441 e. KingsCanyon 1221 Fulton Mall 2048N. FineAve
Fresno,CA 93702 Fresno,CA 93721 Fresno,CA 93727
18 G.CONTRACTOR(S)shall make its internal practices,books,and records relating
19 to the use and disclosure of PHI received from COUNTY, or created or received by the
CONTRACTOR(S)onbehalfof COUNTY,available tothe United States Department of Health and
2 !Human Services upon demand.
22 H.Safeguards
23 CONTRACTOR(S)shall implement administrative,physical,and technical
24 safeguards as required by 45 CFR 164.308,164.310,and 164.312 that reasonably and appropriately
25 protect the confidentiality,integrity,and availability of PHI,including electronic PHI,that it creates,
2 6 receives,maintains or transmits onbehalfof COUNTY;andto prevent access,useor disclosure of
2 7 PHI other than as provided for by this Agreement.CONTRACTOR(S)shall develop and maintain a
2 8 written information privacy and security program that includes administrative,technical and physical
14 -COUNTY OF FRESNO
Fresno,CA
1 safeguards appropriate to the size and complexity of CONTRACTOR(S)'operations and the nature
2 and scope of its activities.Upon COUNTY'S request,CONTRACTOR(S)shall provide COUNTY
3 with information concerning such safeguards.
4 CONTRACTOR(S)shall implement strong access controls and other security safeguards
5 and precautions in order to restrict logical and physical access to confidential,personal (e.g., PHI) or
6 sensitive data to authorized users only. Said safeguards and precautions shall include the following
7 administrative and technical password controls for all systems used to process or store confidential,
8 personal, or sensitive data:
9 1.Passwords must not be:
10 a.Shared or written down where they are accessible or recognizable
11 by anyone else; such as taped to computer screens, stored under keyboards, or visible in a work area;
12 b. A dictionary word;or
13 c.Stored in clear text
14 2.Passwords must be:
15 a. Eight (8)characters or more in length;
16 b.Changed every ninety (90) days;
17 c.Changed immediately if revealed or compromised;and
18 d. Composed of characters from at least three of the following four
19 groups from the standard keyboard:
20 1)Upper case letters (A-Z);
21 2)Lowercase letters (a-z);
22 3) Arabic numerals (0 through 9); and
23 4)Non-alphanumeric characters (punctuation symbols).
24 CONTRACTOR(S)shall implement the following security controls on each workstation
25 orportable computing device(e.g.,laptop computer)containing confidential,
26 personal, or sensitive data:
27 1.Network-based firewall and/or personal firewall;
28 2.Continuously updated anti-virus software; and
15 -COUNTY OF FRESNO
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1 3.Patch managementprocess includinginstallation of all operating
2 system/software vendor securitypatches.
3 CONTRACTOR(S)shall utilize a commercial encryption solution that has received FIPS
4 140-2 validation toencryptall confidential,personal,or sensitive datastoredon portable electronic
5 media (including,butnot limited to,compact disks and thumb drives)andon portable computing
6 devices(including,but not limitedto, laptopandnotebookcomputers).
7 CONTRACTOR(S)shall not transmit confidential,personal,or sensitive datavia e-mail
8 orother internet transport protocol unless thedatais encrypted by a solution thathasbeen validated by
9 the National Institute of Standards and Technology (NIST) as conforming to the Advanced Encryption
10 Standard (AES)Algorithm.
11 I.Mitigation of Harmful Effects
12 CONTRACTOR(S)shall mitigate, to the extent practicable, any harmful effect
13 that is knownto CONTRACTOR(S)of an unauthorizedaccess,viewing, use, disclosure,or breach of
14 PHI by CONTRACTOR(S)orits subcontractor(s)in violation ofthe requirements of these provisions.
15 J.Contractor's Subcontractor(s)
16 CONTRACTOR(S)shallensurethat any of its CONTRACTOR(S)s,including
17 subcontractor(s),if applicable,to whom CONTRACTOR(S)provides PHI received from or created or
18 received by CONTRACTOR(S)onbehalfof COUNTY,agree tothe same restrictions and conditions
19 that apply to CONTRACTOR(S)with respect to such PHI;andto incorporate,when applicable,the
20 relevant provisions of these provisions intoeach subcontract or sub-award to such agents or
21 subcontractor(s).
22 K. Employee Training and Discipline
23 CONTRACTOR(S)shall train and use reasonable measures to ensure
24 compliance with the requirements of these provisions by employees who assist in the performance of
25 functions or activities on behalf of COUNTY under this Agreement and use or disclose PHI and
26 discipline such employees who intentionally violate any provisions of these provisions,including
27 termination of employment.
28 L.Termination for Cause
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1 Upon COUNTY'S knowledge of a material breach of these provisions by
2 CONTRACTOR(S),COUNTY shall either:
3 1.Provide an opportunity for CONTRACTOR(S)to cure the breach or end
4 the violation and terminate this Agreement if CONTRACTOR(S)does not cure the breach or end the
5 violation within the time specified by COUNTY;or
6 2.Immediately terminate this Agreement if CONTRACTOR(S)has
7 breached a material term of these provisions and cure is not possible.
8 3.If neither cure nor termination is feasible,the COUNTY Privacy Officer
9 shall report the violation to the Secretary of the U.S.Department of Health and Human Services.
10 M.Judicial or Administrative Proceedings
11 COUNTY may terminate this Agreement in accordance with the terms and
12 conditions of this Agreement as written hereinabove, if: (1)CONTRACTOR(S)is found guilty in a
13 criminal proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act; or (2)
14 a finding or stipulation that the CONTRACTOR(S)has violated a privacy or security standard or
15 requirement of the HITECH Act, HIPAA;or other securityor privacy laws in an administrativeor
16 civil proceeding in which the CONTRACTOR(S)is a party.
17 N.Effect of Termination
18 Upon termination or expiration of this Agreement for any reason,
19 CONTRACTOR(S)shall return or destroy all PHI received from COUNTY (or created or received by
20 CONTRACTOR(S)on behalf of COUNTY) that CONTRACTOR(S)still maintains in any form, and
21 shallretainno copies of such PHI. Ifreturn or destructionof PHI is not feasible, it shallcontinueto
22 extendthe protections of these provisions to such information,andlimitfurtheruse of suchPHIto
23 those purposesthat make the returnor destruction of suchPHI infeasible. This provision shallapply
24 to PHI that is in the possession of subcontractor(s) or agents,if applicable,of CONTRACTOR(S). If
25 CONTRACTOR(S)destroys the PHI data, a certification of date and time of destruction shall be
26 provided to the COUNTY by CONTRACTOR(S).
27 O.Disclaimer
28 COUNTY makes no warranty or representation that compliance by
17 -COUNTY OF FRESNO
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1 CONTRACTOR(S)with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will be
2 adequate or satisfactory for CONTRACTOR(S)'own purposes or that any information in
3 CONTRACTOR(S)'possession or control, or transmitted or received by CONTRACTOR(S),is or
4 will be secure from unauthorized access,viewing,use,disclosure,or breach.CONTRACTOR(S)is
5 solely responsible for all decisions made by CONTRACTOR(S)regarding the safeguarding of PHI.
6 P.Amendment
7 The parties acknowledge that Federal and State laws relating to electronic data
8 security and privacy are rapidly evolving and that amendment of these provisions may be required to
9 provide for procedures to ensure compliance with such developments.The parties specifically agree to
10 take such action as is necessary to amend this agreement in order to implement the standards and
11 requirements of HIPAA,the HIPAA regulations,the HITECH Act and other applicable laws relating to
12 the security or privacy of PHI.COUNTY may terminate this Agreement upon thirty (30) days written
13 notice in the event that CONTRACTOR(S)does not enter into an amendment providing assurances
14 regarding the safeguarding of PHI that COUNTY in its sole discretion deems sufficient to satisfy the
15 standards and requirements of HIPAA,the HIPAA regulations and the HITECH Act.
16 Q. No Third-Party Beneficiaries
17 Nothing express or implied in the terms and conditions of these provisions is
18 intended to confer,nor shall anything herein confer,upon any person other than COUNTY or
19 CONTRACTOR(S)and their respective successors or assignees,any rights,remedies,obligations or
2 0 liabilities whatsoever.
21 R.Interpretation
22 The terms and conditions in these provisions shall be interpreted as broadly as
23 necessary to implement and comply with HIPAA, the HIPAA regulations and applicable State laws.
24 The parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved in
25 favor of a meaning that complies and is consistent with HEPAA and the HIPAA regulations.
2 6 S.Regulatory References
27 A reference in the terms and conditions of these provisions to a section in the
28 HEPAA regulations means the section as in effect or as amended.
-18 -COUNTY OF FRESNO
Fresno,CA
1 T.Survival
2 The respectiverights and obligations of CONTRACTOR(S)as stated in this
3 Section shall survive the termination or expiration of this Agreement.
4 U.No Waiver of Obligations
5 No change,waiver or discharge of any liabilityor obligation hereunderon any
6 one or more occasions shall be deemed a waiver of performance of any continuing or other obligation,
7 or shallprohibitenforcement of any obligationon any other occasion.
8 20.DATA SECURITY
9 For the purpose of preventing the potential loss, misappropriation or inadvertent access,
10 viewing,useor disclosure of COUNTY data including sensitive or personal client information;abuse
11 of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
12 enter into a contractual relationship with the COUNTY for the purpose of providing services under
13 this Agreement must employ adequate data security measures to protect the confidential information
14 provided to CONTRACTOR(S)by the COUNTY,including butnot limited tothe following:
15 A.CONTRACTOR(S)-Owned Mobile,Wireless,or Handheld Devices
16 CONTRACTOR(S)may not connect to COUNTYnetworksvia personally-
17 owned mobile, wireless or handheld devices, unless the following conditions are met:
18 1)CONTRACTOR(S)has received authorization by
19 COUNTY for telecommuting purposes;
20 2) Current virus protection software is in place;
21 3) Mobile devicehas the remote wipe featureenabled;and
22 4) A secure connection is used.
23 B.CONTRACTOR(S)-Owned Computers or Computer Peripherals
24 CONTRACTOR(S)may not bring CONTRACTOR(S)-owned computers or
25 computer peripherals into the COUNTY for use without prior authorization from the COUNTY'S
26 Chief Information Officer,and/or designee(s),including butnotlimitedto mobile storage devices.If
27 data is approved tobe transferred,data must be stored ona secure server approved by the COUNTY
28
-19 -COUNTY OF FRESNO
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1 and transferred by means of a Virtual Private Network (VPN)connection,or another type of secure
2 connection.Said data must be encrypted.
3 C.COUNTY-Owned Computer Equipment
4 CONTRACTOR(S),including its subcontractor(s)and employees,may not use
5 COUNTY computers or computer peripherals on non-COUNTY premises without prior authorization
6 from the COUNTY'S Chief Information Officer,and/or designee(s).
7 D.CONTRACTOR(S)may not store COUNTY'S private,confidential or sensitive
8 data on any hard-disk drive,portable storage device, or remote storage installation unless encrypted.
9 E.CONTRACTOR(S)shall be responsible to employ strict controls to ensure the
10 integrity and security of COUNTY'S confidential information and to prevent unauthorized access,
11 viewing, use or disclosure of data maintained in computer files, program documentation,data
12 processing systems, data files and data processing equipment which stores or processes COUNTY data
13 internally and externally.
14 F.Confidential client information transmitted to one party by the other by means of
15 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
16 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
17 G.CONTRACTOR(S)is responsible to immediately notify COUNTY of any
18 violations, breaches or potential breaches of security related to COUNTY'S confidential information,
19 data maintained in computer files, program documentation, data processing systems, data files and
20 data processing equipmentwhichstoresorprocesses COUNTY datainternallyor externally.
21 H. COUNTY shall provide oversight to CONTRACTOR(S)'response to all
22 incidentsarisingfrom a possible breach of securityrelatedto COUNTY'Sconfidential client
23 information providedto CONTRACTOR(S).CONTRACTOR(S)willbe responsible to issueany
24 notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole
25 discretion.CONTRACTOR(S)will be responsiblefor all costs incurredas a result of providingthe
26 required notification.
27 21.NON-DISCRIMINATION
28 Duringthe performance ofthis Agreement,CONTRACTOR(S)shallnot unlawfully
-20 -COUNTY OF FRESNO
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1 discriminate against any employee or applicant for employment,or recipient of services,because of
2 race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age
3 or sex,pursuant to all applicable State and Federal statutes and regulations.
4 22.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
5 To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
6 (1) (I)of the Social Security Act, (42 U.S.C.§1395x,sub.(v)(l)[I]),until the expiration of four (4)
7 years after the furnishing of services under this Agreement,CONTRACTOR(S)shall make available,
8 upon written request of the Secretary of the United States Department of Health and Human Services,
9 or upon request of the Comptroller General of the United States General Accounting Office, or any of
10 their duly authorized representatives,a copy of this Agreement and such books, documents, and
11 records as are necessary to certify the nature and extent of the costs of these services provided by
12 CONTRACTOR(S)under this Agreement.CONTRACTOR(S)further agrees that in the event
13 CONTRACTOR(S)carries out any of its duties under this Agreement through a subcontract, with a
14 value or cost of Ten Thousand and No/100 Dollars ($10,000.00)or more over a twelve (12)month
15 period,with a related organization,such Agreementshall contain a clause to the effect thatuntil the
16 expiration of four (4) years after the furnishing of such servicespursuant to such subcontract,the
17 related organizations shall make available, upon written request of the Secretary of the United States
18 Departmentof Health and Human Services,or upon request of the ComptrollerGeneral of the United
19 States General Accounting Office, or any of their duly authorized representatives,a copy of such
20 subcontract and such books,documents,and records of such organization as are necessary to verify the
21 nature and extent of such costs.
22 23.COMPLIANCE
23 CONTRACTOR(S)agreesto complywith the COUNTY'SCONTRACTOR(S)Code of
24 Conduct and Ethics and the COUNTY'S Compliance Program in accordance with Exhibit F. Within
25 thirty(30)daysof enteringintothe agreement withthe COUNTY,CONTRACTOR(S)shallhaveall
26 of CONTRACTOR(S)'s employees, agents and subcontractor(s) providing services under this
27 Agreement certifyin writing,thatheor shehas received,read,understood,andshall abide bythe
28 CONTRACTOR(S)Codeof Conductand Ethics.CONTRACTOR(S)shallensurethat withinthirty
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1 (30)days of hire, all new employees,agents and subcontractor(s)providing servicesunder this
2 Agreement shallcertifyin writing thatheor shehas received,read,understood,andshall abide bythe
3 CONTRACTOR(S)Code of Conduct and Ethics. CONTRACTOR(S)understandsthat the promotion
4 of and adherence to the Code of Conduct is an element in evaluating the performance of
5 CONTRACTOR(S)and its employees, agents and subcontractor(s).
6 Within thirty (30) days of entering into this Agreement, and annually thereafter, all
7 employees,agents and subcontractor(s)providing services underthis Agreement shall complete
8 general compliance training and appropriate employees,agents and subcontractor(s)shall complete
9 documentation andbillingor billing/reimbursement training.All new employees,agentsand
10 subcontractor(s)shallattendthe appropriate training within30daysof hire.Each individual whois
11 required to attend training shall certify in writing thatheorshehas received the required training.The
12 certification shallspecifythetypeof training received andthedate received.The certification shall be
13 provided tothe COUNTY'S Compliance Officer at 3133 N.Millbrook,Fresno,CA 93703.
14 CONTRACTOR(S)agrees to reimburse COUNTY fortheentirecostof anypenalty imposed upon
15 COUNTY bythe Federal Government asa result of CONTRACTOR(S)'s violation ofthe terms of
16 this Agreement.
17 24.ASSURANCES
18 In entering intothis Agreement,CONTRACTOR(S)certifies thatitnoranyofits officers
19 arenot currently excluded,suspended,debarred,or otherwise ineligible to participate in the Federal
20 Health Care Programs:thatitoranyofits officers have notbeen convicted ofa criminal offense
21 related to the provision of health care items or services;nor has itorits officers been reinstated to
22 participation in the Federal Health Care Programs after a period of exclusion,suspension,debarment,
23 or ineligibility.If COUNTY learns,subsequent to entering into a contract,that CONTRACTOR(S)is
24 ineligible on these grounds,COUNTY will remove CONTRACTOR(S)from responsibility for,or
25 involvement with,COUNTY'S business operations related to the Federal HealthCare Programs and
26 shallremovesuch CONTRACTOR(S)fromanypositioninwhich CONTRACTOR(S)'compensation,
27 orthe itemsor services rendered,orderedorprescribedby CONTRACTOR(S)maybe paidinwhole
28 or part,directly or indirectly,by Federal Health Care Programs or otherwise with Federal Funds at
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1 least until such time as CONTRACTOR(S)is reinstated into participation in the Federal Health Care
2 Programs.
3 A.If COUNTY has notice that CONTRACTOR(S)or its officers has been charged
4 with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion to
5 during the term on any contract,CONTRACTOR(S)and COUNTY shall take all appropriate actions
6 ensure the accuracy of any claims submitted to any Federal Health Care Program.At its discretion
7 given such circumstances,COUNTY may request that CONTRACTOR(S)cease providing services
8 until resolution of the charges or the proposed exclusion.
9 B.CONTRACTOR(S)agrees that all potential new employees of
10 CONTRACTOR(S)or Subcontractor(s)of CONTRACTOR(S)who, in each case, are expected to
11 perform professional services Under this Agreement,will be queried as to whether (1) they are now or
12 ever have been excluded,suspended,debarred, or otherwise ineligible to participate in the Federal
13 Health Care Programs;(2) they have been convicted of a criminal offense related to the provision of
14 health care items or services;and or (3)they have been reinstated to participation in the Federal Health
15 Care Programs after a period of exclusion,suspension,debarment,or ineligibility.
16 1.In the event the potential employee or subcontractor(s)informs
17 CONTRACTOR(S)that he or she is excluded,suspended,debarred or otherwise ineligible,or
18 has been convicted of a criminal offense relating to the provision of health care services,and
19 CONTRACTOR(S)hires or engages such potential employee or subcontractors(s),
20 CONTRACTOR(S)will ensure that said employee or subcontractors(s)does no work,either directly
21 or indirectly relating to services provided to COUNTY.
22 2.Notwithstanding the above,COUNTY at its discretion may terminate this
23 Agreement in accordance with Section Four (4)of this Agreement,or require adequate assurance (as
24 defined by COUNTY)that no excluded,suspended or otherwise ineligible employee or
25 subcontractors(s)of CONTRACTOR(S)will perform work,either directly or indirectly,relating to
26 services provided to COUNTY.Such demand for adequate assurance shall be effective upon a time
27 frame to be determined by COUNTY to protect the interests of COUNTY clients.
28 C.CONTRACTOR(S)shall verify (by asking the applicable employees and
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1 subcontractor(s)that all current employees and existing subcontractors(s)who, in each case, are
2 expected to perform professional services under this Agreement (1)are not currently excluded,
3 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
4 have not been convicted of a criminal offense related to the provision of health care items or services;
5 and (3) have not been reinstated to participation in the Federal Health Care Program after a period of
6 exclusion, suspension, debarment, or ineligibility. In the event any existing employee or
7 subcontractor(s)informs CONTRACTOR(S)that he or she is excluded,suspended,debarred or
8 otherwise ineligible to participate in the Federal Health Care Programs, or has been convicted of a
9 criminal offense relating to the provision of health care services,CONTRACTOR(S)will ensure that
10 saidemployeeor subcontractor(s)does no work, eitherdirect or indirect,relating to servicesprovided
11 to COUNTY.
12 1.CONTRACTOR(S)agrees to notify COUNTY immediately during the
13 term of this Agreement whenever CONTRACTOR(S)learns that an employee or subcontractors)
14 who, in each case, is providing professional services under Section One (1)this Agreement is
15 excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care
16 Programs,or is convictedof a criminaloffenserelatingto theprovision of healthcare services.
17 2.Notwithstanding the above, COUNTY at its discretion may terminate this
18 Agreement in accordance with the Termination SectionFour(4)of this Agreement,orrequire
19 adequate assurance (asdefinedby COUNTY)thatno excluded,suspendedor otherwise ineligible
20 employee or subcontractor(s)of CONTRACTOR(S)will perform work,either directly or indirectly,
21 relating to servicesprovidedto COUNTY.Suchdemandforadequate assurance shallbe effective
22 uponatime frame tobe determined by COUNTY toprotectthe interests of COUNTY clients.
23 D. CONTRACTOR(S) agrees to cooperate fully with any reasonable requests for
24 information from COUNTY which may be necessary to complete any internal or external audits
25 relating to CONTRACTOR(S)'s compliance withthe provisions of this Section.
26 E.CONTRACTOR(S)agrees to reimburse COUNTY for the entire cost of any
27 penalty imposed upon COUNTY bythe Federal Government as a resultof CONTRACTOR(S)'s
28 violation of CONTRACTOR(S)'obligations as described in this Section.
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1 25.PROHIBITION ON PUBLICITY
2 None of the funds,materials,property or services provided directly or indirectly under
3 this Agreement shall be used for CONTRACTOR(S)'advertising, fundraising, or publicity (i.e.,
4 purchasing of tickets/tables,silent auction donations, etc.) for the purpose of self-promotion.
5 Notwithstanding the above,publicity of the services described in Section One (1)of this Agreement
6 shall be allowed as necessary to raise public awareness about the availability of such specific services
7 when approved in advance by COUNTY'S DBH Director or designee and at a cost to be provided in
Section Five (5)of this Agreement for such items as written/printed materials,the use of media (i.e.
9 radio,television,newspapers)and any other related expense(s).
10 26.PROPERTY OF COUNTY
11 A.COUNTY and CONTRACTOR(S)recognizes that fixed assets are tangible and
12 intangible property obtained or controlled under COUNTY'S Mental Health Plan for use in operational
13 capacityand will benefit COUNTY for a period more than one year. Depreciation of the qualified
14 items will be on a straight-line basis.
15 For COUNTY purposes, fixed assets must fulfill three qualifications:
16 1.Asset must have life span of over one year.
17 2.The asset is not a repair part.
18 3. The asset must be valued at or greater than the capitalization thresholds for
19 the asset type:
20
21
22
23
24
25
26
27
28
Asset type Threshold
•land $0
•buildings and improvements $100,000
•infrastructure $100,000
• be tangible $5,000
o equipment
o vehicles
• or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
• and capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY.If it is
approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed asset
log will be maintained by COUNTY'S Asset Management System and annual inventory until the asset
is fully depreciated.During the terms of this Agreement,CONTRACTOR(S)'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
Director or designee.CONTRACTOR(S)maintains a tracking system on the items and are not
required to be capitalize or depreciated. The items are subject to annual inventory for compliance.
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement.CONTRACTOR(S)agrees to
participatein an annual inventory of all COUNTY fixedand inventoriedassets. Upon terminationor
expiration of this Agreement CONTRACTOR(S) shall be physically present when fixed and
inventoried assets are returned to COUNTY possession.CONTRACTOR(S)is responsible for
returningto COUNTYall COUNTYownedundepreciatedfixed and inventoried assets, or the
monetaryvalue of said assets if unable to produce the assetsat the expirationor termination of this
Agreement.
CONTRACTOR(S)further agrees to the following:
2 9 1.To maintain all items of equipment in good working order and condition,
23
24
25
26
normal wear and tear is expected;
2. To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as requiredby COUNTY andto maintainan inventorylistshowing
where and how the equipment is being used, in accordance with procedures developed by
27 COUNTY.All such lists shall be submitted to COUNTY within ten (10)days of any request
2 8 therefore;and
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1 3. To report in writing to COUNTY immediately after discovery,the lost or
2 theft of any items of equipment.For stolen items, the local law enforcement agency must be contacted
3 and a copy of the police report submitted to COUNTY.
4 D. The purchase of any equipment by CONTRACTOR(S)with funds provided
5 hereunder shall require the prior written approval of COUNTY'S DBH,shall fulfill the provisions of
6 this Agreement as appropriate,and must be directly related to CONTRACTOR(S)'s services or
7 activity under the terms of this Agreement. COUNTY'S DBH may refuse reimbursement for any costs
8 resulting from equipment purchased,which are incurred by CONTRACTOR(S),if prior written
9 approval has not been obtained from COUNTY.
10 E.CONTRACTOR(S)must obtain prior written approval from COUNTY'S DBH
11 whenever there is any modification or change in the use of any property acquired or improved,in
12 whole or in part, using funds under this agreement.If any real or personal property acquired or
13 improved with said funds identified herein is sold and/or is utilized by CONTRACTOR(S)for a use
14 which does not qualify under this program,CONTRACTOR(S)shall reimburse COUNTY in an
15 amount equal to the current fair market value of the property, less any portion thereof attributable to
16 expendituresof non-program funds. These requirementsshallcontinue in effect for the life of the
17 property. Inthe eventthe program is closed out, the requirementsforthis Section Twenty-One (21)
18 shall remain in effect for activities or property funded with said funds, unless action is taken by the
19 State government to relieve COUNTY of these obligations."
20 27.CULTURAL COMPETENCY
21 As related to Cultural and Linguistic Competence,CONTRACTOR(S)shall
22 comply with:
23 A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C.section 2000d, and 45 C.F.R.
24 Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
25 fromdiscriminatingagainst personsbased on race, color, national origin, sex, disabilityor religion.
26 Thisis interpreted to meanthata limitedEnglishproficient(LEP)individual is entitledto equalaccess
27 and participation infederallyfunded programs through theprovisionof comprehensive andquality
28 bilingual services.
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1 B.Policies and procedures for ensuring access and appropriate use of trained
2 interpreters and material translation services for all LEP clients, including, but not limited to, assessing
3 the cultural and linguistic needs of its clients,training of staff on the policies and procedures,and
4 monitoring its language assistance program.The CONTRACTOR(S)'procedures must include
5 ensuring compliance of any sub-contracted providers with these requirements.
6 C.CONTRACTOR(S)shall not use minors as interpreters.
7 D.CONTRACTOR(S)shall provide and pay for interpreting and translation services
8 to persons participating in CONTRACTOR(S)'services who have limited or no English language
9 proficiency,including services to persons who are deaf or blind.Interpreter and translation services
10 shall be provided as necessary to allow such participants meaningful access to the programs,services
11 and benefits provided by CONTRACTOR(S).Interpreter and translation services,including
12 translation of CONTRACTOR(S)'"vital documents"(those documents that contain information that is
13 critical for accessing CONTRACTOR(S)'services or are required by law) shall be provided to
14 participants at no cost to the participant.CONTRACTOR(S)shall ensure that any employees,agents,
15 subcontractor(s),or partners who interpret or translate for a program participant,or who directly
16 communicate with a program participant in a language other than English,demonstrate proficiency in
17 the participant's language and can effectively communicate any specialized terms and concepts
18 peculiar to CONTRACTOR(S)'services.
19 E. In compliance with the State mandated Culturally and Linguistically Appropriate
20 Services standards as published by the Office of Minority Health,CONTRACTOR(S)must submit to
21 COUNTY for approval,within sixty (60) days from date of contract execution,CONTRACTOR(S)'
22 plan to address all fifteen national cultural competency standards as set forth in the "National
23 Standards on Culturally and Linguistically Appropriate Services (CLAS)"
24 http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf.COUNTY'S annual on-site review of
25 CONTRACTOR(S)shall include collection of documentation to ensure all national standards are
26 implemented. As the national competency standards are updated,CONTRACTOR(S)'plan must be
27 updated accordingly.
28 28.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
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1 INFORMATION
2 Thisprovisionis only applicable if CONTRACTOR(S)is a disclosing entity,
3 fiscal agent,or managed careentityas defined inCodeof Federal Regulations (C.F.R),Title42 §
4 455.101 455.104,and 455.106(a)(l),(2).
5 In accordance with C.F.R.,Title 42 §§455.101, 455.104,455.105 and
6 455.106(a)(l ),(2), the following information mustbe disclosedby CONTRACTOR(S)by completing
7 ExhibitG, "Disclosure of Ownershipand Control Interest Statement",attached hereto and by this
8 reference incorporated herein and made part of this Agreement.CONTRACTOR(S)shall submit this
9 formto COUNTY'SDBH within thirty(30) days of the effectivedate of this Agreement.Additionally,
10 CONTRACTOR(S)shall report any changes to this information within thirty-five (35) days of
11 occurrence by completing Exhibit G,"Disclosure of Ownership and Control Interest Statement."
12 Submissions shall be scanned pdf copies and are to be sent via email to
13 DBHAdministration@co.fresno.ca.us attention:Contracts Administration.
14 29.DISCLOSURE -CRIMINAL HISTORY AND CIVIL ACTIONS
15 CONTRACTOR(S)is required to disclose if any of the following conditions
16 apply to them, their owners, officers, corporate managers and partners (hereinafter collectively
17 referred to as "CONTRACTOR(S)"):
18 A.Within the three-year period preceding the Agreement award, they have been
19 convicted of, or had a civil judgment rendered against them for:
20 1.Fraud or a criminal offense in connection with obtaining,attempting to
21 obtain,or performing a public (federal,state, or local)transaction or contract under a public
2 2 transaction;
23 2.Violation of a federal or state antitrust statute;
24 3.Embezzlement,theft,forgery,bribery,falsification,or destruction of
2 5 records;or
26 4.False statements or receipt of stolen property.
27 B.Within a three-year period preceding their Agreement award,they have had a
28 public transaction (federal,state, or local)terminated for cause or default.
-29 -COUNTY OF FRESNO
Fresno,CA
1 Disclosure of the above information will not automatically eliminate
2 CONTRACTOR(S) from further business consideration. The information will be considered as part
3 of the determination of whether to continue and/or renew the Contract and any additional
4 information or explanation that a CONTRACTOR(S)elects to submit with the disclosed information
5 will be considered. If it is later determined that the CONTRACTOR(S)failed to disclose required
6 information, any contract awarded to such CONTRACTOR(S)may be immediately voided and
7 terminated for material failure to comply with the terms and conditions of the award.
8 CONTRACTOR(S)must sign a "Certification Regarding Debarment, Suspension, and
9 Other Responsibility Matters-Primary Covered Transactions"in the form set forth in Exhibit H,
10 attached hereto and by this reference incorporated herein.Additionally,CONTRACTOR(S)must
11 immediately advise the County in writing if,during the term of this Agreement:(1)
12 CONTRACTOR(S)becomes suspended,debarred,excluded or ineligible for participation in federal
13 or state funded programs or from receiving federal funds as listed in the excluded parties'list system
14 (http://www.sam.gov);or (2) any of the above listed conditions become applicable to
15 CONTRACTOR(S).CONTRACTOR(S)shall indemnify,defend and hold the COUNTY harmless
16 for any loss or damage resulting from a conviction,debarment,exclusion,ineligibility or other matter
17 listed in the signed Certification Regarding Debarment,Suspension,and Other Responsibility
18 Matters."
19 30.COMPLAINTS
20 CONTRACTOR(S)shall log complaints and the disposition of all complaints from a
21 client or a client's family.CONTRACTOR^)shall provide a copy of the detailed complaint log
22 entries concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th)
23 day of the following month,in a format that is mutually agreed upon.Besides the detailed complaint
24 log,CONTRACTOR(S)shall provide details and attach documentation of each complaint with the
25 log.CONTRACTOR(S)shall post signs informing clients of their right to file a complaint or
26 grievance.CONTRACTOR(S)shall notify COUNTY of all incidents reportable to state licensing
27 bodies that affect COUNTY clients within twenty-four (24)hours of receipt of a complaint.
28
-30 -COUNTY OF FRESNO
Fresno,CA
1 Within ten (10)days after each incident or complaint affecting COUNTY-sponsored
2 clients,CONTRACTOR(S)shall provide COUNTY with information relevant tothe complaint,
3 investigative detailsof the complaint,the complaintand CONTRACTOR(S)'disposition of,or
4 corrective action taken to resolve the complaint.In addition,CONTRACTOR(S)shall inform every
5 clientoftheirrightsas set forth in Exhibit I.CONTRACTOR(S)shallfilean incident report forall
6 incidents involving clients, following the Protocol and using the Worksheet identified in Exhibit I.
7 31.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR(S)is operatingas a corporation
9 (a for-profit or non-profit corporation)or if duringthe term of this agreement,the CONTRACTOR(S)
10 changes its status to operate as a corporation.
11 Members ofthe CONTRACTOR(S)'Boardof Directors shalldiscloseany self-dealing
12 transactions thattheyare a partyto while CONTRACTOR(S)is providinggoodsor performing
13 services under this agreement.A self-dealing transaction shall mean a transaction to which the
14 CONTRACTOR(S)is a party and in which one or more of its directors has a material financial
15 interest. Members of the Board of Directorsshall disclose any self-dealingtransactionsthatthey are a
16 party to by completing and signing a Self-Dealing Transaction Disclosure Form (Exhibit J) attached
17 heretoand by this reference incorporatedherein and madepart of this Agreement) and submittingit to
18 the COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
19
20 32.SEPARATE AGREEMENT
21 It is mutually understood by the parties that this Agreement does not, in any way, create a
22 joint venture among CONTRACTOR(S).By execution of this Agreement,CONTRACTOR(S)
23 understand that a separate Agreement is formed between each individual CONTRACTOR and
24 COUNTY.
25 33.AUDITS AND INSPECTIONS
26 The CONTRACTOR(S)shall any time during business hours,and as often as the
27 COUNTY may deem necessary,make available to the COUNTY for examination all of its records and
28 data with respect to the matters covered by this Agreement.The CONTRACTOR(S)shall, upon
31 -COUNTY OF FRESNO
Fresno,CA
1 request by the COUNTY, permit the COUNTY to audit and inspect all such records and data
2 necessary to ensure CONTRACTOR(S)'s compliance with the terms of this Agreement.
3 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
4 CONTRACTOR(S)shall be subject to the examination and audit of the State Auditor General for a
5 period of three (3) years after final payment under contract (Government Code section 8546.7).
6 34.NOTICES
7 The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
9 COUNTY CONTRACTOR(S)
Director,Fresno County SEE EXHIBIT A
10 Department of
Behavioral Health
3133 N.Millbrook Ave
11
12 Fresno,CA 93703
13 Any and all notices between COUNTY and CONTRACTOR(S)provided for or
14 permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
15 personally delivered to one of the parties,or in lieu of such personal service,when deposited in the
16 United States Mail,postage prepaid,addressed to such party.
17 35.GOVERNING LAW
18 Venue for any action arising out of or related to this Agreement shall only be in Fresno
19 County,California.
20 The rights and obligations of the parties and all interpretation and performance of this Agreement
21 shall be governed in all respects by the laws of the State of California.
22 36.ENTIRE AGREEMENT
23 This Agreement,including all Exhibits between CONTRACTOR(S)and COUNTY,RFQ
24 #070-5331 and responses to RFQ #070-5331 with respect to the subject matter hereof and supersedes
25 all previous agreement negotiations,proposals,commitments,writings,advertisements,publications,
26 and understandings of any nature whatsoever unless expressly included in this Agreement.
2 7 ///
28 ///
32 -COUNTY OF FRESNO
Fresno,CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written.
3 ATTEST:
4 CONTRACTOR(S)
5 PLEASE SEE SIGNATURE
PAGES ATTACHED
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COUNTY OF FRESNO
Chairman, Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
-33 -COUNTY OF FRESNO
Fresno, CA
1 APPROVED AS TO LEGAL FORM:
DANIEL C.CEDERBORG,COUNTY COUNSEL
3
4
5
6 APPROVED AS TO ACCOUNTING FORM:
VICKI CROW,C.P.A.,AUDITOR-CONTROLLER/
7 TREASURER-TAX COLLECTOR
9
10
11 REVIEWED AND RECOMMENDED FOR
12 APPROVAL:
13
14
By.ijicLx Cask
15 By_
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Dawan Utecht,Director
1 ^Department of Behavioral Health
17
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Fund/Subclass:0001/10000
19 Account/Program:7295/0
Organizations/Cost Centers:5630/2175,5630/2820,5630/4781
Fiscal Year (FY)Program Cost
FY 2015-16 $100,000
FY 2016-17 $100,000
FY 2017-18 $100,000
FY 2018-19 $100,000
FY 2019-20 $100,000
III
///
///
34 -COUNTY OF FRESNO
Fresno,CA
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COMFORT MED TRANS,INC.
By JiU %<
Print Name rMVsrrl tftUV^UVS
Title V^^V\lVvV
Secretary of Corporation,or
Any Assistant Secretary,or
9 Chief Financial Officer,or
Any Assistant Treasurer
Bv "0 ^(j
16 PrintName^l^!^
17
18 Title C**AA^<-VKVt^Vr
19
Secretary of Corporation,or
Any Assistant Secretary,or
2 0 Chief Financial Officer,or
Any Assistant Treasurer
21
22
23
24
25
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27
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Mailing Address:
Comfort Med Trans,Inc.
4272 N.Selland
Fresno,CA 93722
(559)227-6862
Contact: Suzy Martirosyan, Executive Director
35 -COUNTY OF FRESNO
Fresno,CA
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NEMT So
By_
s,LLClutten
V 0 i
c~>cc>1\~tor cPrint Name_
Title ceo
Secretary of Corporation,or
Any Assistant Secretary,or
Chief Financial Officer,or
Any Assistant Treasurer
Ti
Print Name ^i \OJt^^f
Title C €TD
Secretary of Corporation,or
Any Assistant Secretary,or
Chief Financial Officer,or
Any Assistant Treasurer
Mailing Address:
NEMT Solutions
24167 Cruise Circle Dr.
Canyon Lake, CA 92587
(951)244-9413
Contact:Scott West,CEO
<,
-36
101 5
COUNTY OF FRESNO
Fresno,CA
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ON CALL TRANSPORT,INC.
Print Name L\f)G(Ck (&o f^T
Title
Secretary of Corporation,or
Any Assistant Secretary,or
Chief Financial Officer,or
Any Assistant Treasurer
Oi^/i^r
J HiAiiir'"^*^•e
Print Name \ /<(K,(U^\JC4&<
Title CJTt>/0U/>/-fciC_
Secretary of Corporation,or
Any Assistant Secretary,or
Chief Financial Officer,or
Any Assistant Treasurer
Mailing Address:
On Call Transport,Inc.
1942 Cromwell Avenue
Clovis,CA 93611
(559)248-9100
Contact:Linda Cooper,Owner
37 COUNTY OF FRESNO
Fresno,CA
List of Contractors
Comfort Med Trans,Inc.
4272 N.Selland
Fresno,CA 93722
(559)227-6862
Suzy Martirosyan, Executive Director
NEMT Solutions
24167 Cruise Circle Drive
Canyon Lake, CA 92587
(951)244-9413
Scott West,CEO
On Call Transport,Inc.
1942 Cromwell Avenue
Clovis,CA 93611
(559)248-9100
Contact:Linda Cooper,Owner
Exhibit A
Exhibit B
Page 1 of 2
Scope of Work
CONTRACTOR(S)shall provide drivers to provide services twenty-four (24)hours per day,seven (7)days a
week,to transport mental health clients from Fresno County to out-of-county mental health facilities,and
scheduled transportation from out-of-county to Fresno County mental health facilities on an as-needed basis.
CONTRACT AMOUNT:
FY 2015-16 $100,000.00
FY 2016-17 $100,000.00
FY 2017-18 $100,000.00
FY 2018-19 $100,000.00
FY 2019-20 $100,000.00
Total Contract Amount $500,000.00
CONTRACTOR^)'RESPONSIBILITIES:
1) Contractor(s) shall provide transportation services of persons discharged from facilitiesoutside of
Fresno County to locations within Fresno County.
2) Service will include traveling to facilities designated by the Department of Behavioral Health to pickup
identified persons and transport them to a residence,facility, or alternative location as per discharge
instructions.
3) The residence,facility,or alternative location for drop offof individuals may be anywhere within Fresno
County limits,including the metropolitan area of Fresno/Clovis as well as all rural communities in
Fresno County.
4)Locations of designated facilities outside of Fresno County to pick up persons may include, but not be
limited to,Visalia,Bakersfield,Merced,Ventura and Sacramento.
5) Contractor(s) shall provide two or more drivers when safety issues deemed necessary,when
transporting two or more people, or when deemed necessary by Fresno County DBH.
6)Transports may include between one and five persons per trip.
7)Transports may be required more than once per day.
8) Transportation services are to be available Monday through Friday,weekends and holidays.
9) Contractor(s)shall providetransportation services for persons who have wheelchairs, walkers,other
medical devices/needs,or who may require Hoyer lifts.
10)Service will include traveling to designated facilities throughoutthe State to pickup individuals and
transport them to Fresno Countyforan appointment.Service may includereturn transport to the
designated facility on the same day or nextday as determined bythe Countyof Fresno. Transportsfor
these individuals will typically have 24 hour advanced notice.
Exhibit B
Page 2 of 2
11)Service may also include traveling to designated facilities throughout the State to pick up an individual
and transport him/her to a different facility.Transports for these individuals may have four hours
advanced notice.
12)Contractor(s)shall participate in general compliance training provided by the County within 45-60 days
of contract execution,Mental Health First Aid (MHFA),code of conduct training,ethics training,and
other training deemed appropriate by Department of Behavioral Health for client safety and awareness.
13)Services to be provided on the initial request for Service.
COUNTY RESPONSIBILITIES:
1)County shall provide general compliance training within 45-60 days of contract execution,Mental
Health first aid (MHFA),code of conduct,ethics training,and other training deemed appropriate for the
vendor by the department to better assist DBH clients.
2)County shall provide as much advance notice as possible with a two (2) hour minimum on all transports
to Contractor(s)when transportation service is needed.Exhibit B -(Sample Medical Transport
Transportation Request Form)is an example of how the County will contact the contractor(s).
3)County shall notify Contractor(s)of the pickup location of each person and the destination to where
he/she is to be transported.
4)County shall be available to provide information as quickly as possible to Contractor(s)in the event that
a person is not at the pick-up site when services are requested.
a) For transports of persons discharged from hospital facilities,Contractor(s)may call the
Department of Behavioral Health,attention Hospital Transport Liaison,at (559)600-4099.
b) For transports of severely mentally ill persons transported to/from residential facilities,
Contractor(s)may call the Department of Behavioral Health attention,Conservatorship Team,at
(559)600-4099.
5)Initial request for Service will provide the contact name of the County representative requesting the
service,client information,pickup and drop off location,payment information and any special
instructions with regard to client transport.
QUOTATION SCHEDULE
Exhibit C-1
Comfort Med Trans,Inc.
Vehicle Type Maximum Rate Rate Additional
(Van/Car/Bus
Passengers
(from/to (from/to Out of
Charges
w/safety (Per vehicle type)Fresno/Clovis Town)(if applicable)
enclosure)area)
Van 5 $25.00/response $25.00/response Sundays/Holidays
$2.50/mile $2.50/mile
$1.00/mile empty
$25.00 surcharge
Car 4 $25.00/response $25.00/response Sundays/Holidays
$2.50/mile $2.50/mile
$1.00/mile empty
$25.00 surcharge
Bidderto identify each type of vehicle and specify the number of Vans,Cars and Wheelchair Accessible
Vans available for transport services.
Vehicle Type Number Available for Service
Van 17
Car 3
Vehicle Type
(Van/Car/Bus
w/safety
enclosure)
SEDAU'MiNI VAN
CAQED CAWMIN1 VAN
WHEELCHAIR VAN
QUOTATION SCHEDULE
Maximum
Passengers
(Per vehicle type)
5 AMBULATORY
T
Rata
(from/to
Fresno/Clevis
area)
$35.00 ONE WAY
Rate
(fromAoOutof
Town)
$35.00 ONE WAY
8AMBULATORY |$40.00 ONE WAY I $40.00 ONE WAY
2WH6EL^!r I M0.00ONBWAV j $fl0.00ONEWAY
1
Exhibit C-2
NEMT Solutions
Page 18
Additional
Charges
(If applicable)
tzn PER MILE
AND
$30.00 AOPLATTD
$100 PER MILE
AND
$3.00 PER MILE
AND
Biddtf to identify each type of veWdt and specify tha number of Vans,Gars,and Whtttohtjr
AccessibleVans available for transport services,
Vehicle Typo
WHEELCHAWVAN
MINI VAN (CAN BE CAGED)
SEDAN
CAGED CAR SEDAN
Number Available for Service
to
4
2
2
QUOTATION SCHEDULE
Exhibit C-3
On-Call Transport, Inc.
Vehicle Type
(Van /Car /Bus
with safety
enclosure)
Maximum
Passengers
(Per vehicle type)
Rata
(from/to
Fresno/Clovis
area)
Rata
(from/to Out of
Town)
Additional
Charges
(if applicable)
Car 3 Ambulatory
$20.00 per
Round-trip,plus
$2.00 per mile
$20.00 per
Round-trip plus
$2.00 per mile,
plus $0.40 per
empty mile
Wait time:
$30.00 per hour
No Show:
$10.00(car)
No Show;
$20.00 (van)
Caged Car 3 Ambulatory
$20.00 per
Round-Trip plus
$2.00 per mile
$20.00 per
Round-trip plus
$2.00 per mile,
plus $0.40 per
empty mile
Wait time:
$30.00 par hour
No Show:
$10.00(car)
No Show:
$20.00 (van)
Van
5 ambulatory or
3 Ambulatory 2
Wheelchairs
$40.00 per
Round-trip,plus
$2.20 per mile
$40.00 Per
Round Trip Plus
$2.20 per mile,
plus $0.50 per
empty mile
Wait time:
$30.00 per hour
No Show:
$10.00(car)
No Show:
$20.00 (van)
Bidderto identify each type ofvehicle and specify the number of Vans,Cars,and Wheelchair
Accessible Vans available for transport services.
Vehicle Type Number Available for Service
2 Vans 1
1 SUV 1
2 Cars 1
Exhibit D
Service Analysis
Cmcnn fniintY DBH 07/01/XX -06/30/XX
Gurney
Total Miles Add'l Attendant
Wheelchair
Total Miles Add'l Attendant
January
February
March
April
May
June
July
August
September
October
November
December
0
0
0
0
0
0
0
0
0
0
0
0
0 0 January
February
March
April
May
June
July
August
September
October
November
December
0
0
3
2
0
0
1
2
2
2
0
0
0 0
0 0 0 0
0 0 132 0
0 0 12 0
0 0 0 0
0 0 0 0
0 0 6 0
0 0 12 0
0 0 362 0
0 0 12 2
0 0 0 0
0 0 0 0
0 0 0 12 536 2
Safety Enclosure
Total Miles Add'l Attendant
Ambulatory
(Non-Safety
Enclosure)Total Miles Add'l Attendant
January
February
March
April
May
June
July
August
September
October
November
December
10
14
20
4
0
0
3
12
10
9
10
7
1,216 0 January
February
March
April
May
June
July
August
September
October
November
December
3
8
28
28
0
0
8
12
9
2
3
7
382 0
2,479 0 428 0
1,929 0 1,522 0
712 0 2,240 0
0 0 0 0
0 0 0 0
348 0 394 0
1,677 0 638 0
1,550 9 764 0
2,447 6 95 0
1,378 0 109 0
1,179 0 299 0
99 14,915 15 108 6,871 0
State Mental Health Requirements Exhibit E
Page 1 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
A.COURT shall comply with applicable laws and regulations,including but not
limited to section 5328 et seq.of the Welfare and Institutions Code regarding the
confidentiality of patient information.
B.COURT shall protect,from unauthorized disclosure,names and other identifying
information concerning persons receiving services pursuant to this contract,
except for statistical information.This pertains to any and all persons receiving
services pursuant to a Department ofMental Health funded program.COURT
shall not use such identifying information for any purpose other than carrying out
the COURT'S obligations under this contract.
C.COURT shall not disclose,except as otherwise specifically permitted by this
contract or authorized by the client/patient,any such identifying information to
anyone other than the County or State without prior written authorization from
the County or State in accordance with State and Federal laws.
D.For purposes ofthe above paragraphs,identifying information shall include,but
not be limited to,name,identifying number,symbol,or other identifying
particular assigned to the individual,such as finger or voice print,or a
photograph.
4.NONDISCRIMINATION
A.COURT shall not employ any unlawful discriminatory practices in the admission
of patients,assignment of accommodations,treatment,evaluation,employment
of personnel,or in any other respect on the basis of race,color,gender,religion,
marital status,national origin,age,sexual preference,or mental or physical
handicap,in accordance with the requirements of applicable Federal or State
Law.
State Mental Health Requirements Exhibit E
Page 2 of2
B.During the performance of this contract,COURT shall not unlawfully
discriminate against any employee or applicant for employment because of race,
religion,color,national origin,ancestry,mental or physical handicap,medical
condition,marital status,age,or sex.COURT shall comply with the provisions
of the Americans with Disabilities Act of 1990,the Fair Employment and
Housing Act (Government Code,section 12900,et seq.),and the applicable
regulations promulgated thereunder (California Code of Regulations,Title 2,
section 7285 et seq.).COURT shall ensure that the evaluation and treatment of
their employees and applicants for employment are free ofsuch discrimination.
The applicable regulations of the Fair Employment and Housing Commission
implementing Government Code,section 12990,set forth in Chapter 5,Division
4of Title 2of the California Code of Regulations are incorporated into this
contract by reference and made a part hereof as ifset forth in full.COURT shall
give written notice of its obligations under this clause to labor organizations with
which they have a collective bargaining or other agreement.
C.COURT shall comply with the provisions of section 504 ofthe Rehabilitation
Act of 1973,as amended,pertaining to the prohibition of discrimination against
qualified handicapped persons in all federally assisted programs or activities,as
detailed in regulations signed by the Secretary of Health and Welfare Agency,
effective June 2,1977,and found in the Federal Register,Volume 42,No.86,
dated May 4, 1977.
PATIENTS'RIGHTS
COURT shall comply with applicable laws and regulations,including but not limited to,
laws,regulations,and State policies relating to patients'rights.
Exhibit F
Page 1of 5
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committedto full compliancewith all applicable laws,
regulations,rules and guidelines that apply tothe provision and payment of mental health services.
Mentalhealthcontractors and the manner in whichthey conductthemselves are a vital partofthis
commitment.
FresnoCountyhas establishedthis Contractor Codeof ConductandEthicswith which
contractor andits employees and subcontractors shall comply.Contractor shall require its employees
and subcontractors to attenda compliance training thatwillbe provided byFresno County.After
completion ofthis training,each contractor,contractor's employee and subcontractor must sign the
ContractorAcknowledgmentand Agreementformandreturnthis form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1.Complywith all applicablelaws,regulations,rulesorguidelineswhen providingand billing
for mental health services.
2. Conductthemselves honestly, fairly,courteouslyand with a high degree of integrityintheir
professional dealingrelatedtotheir contractwiththe Countyand avoidanyconduct that could
reasonablybe expected to reflect adverselyupon the integrity of the County.
3. TreatCountyemployees,consumers,andothermentalhealthcontractorsfairlyand with
respect.
4. NOT engage in any activity in violationofthe County's Compliance Program, nor engage in
any otherconduct which violates anyapplicablelaw, regulation, rule or guideline
5. Take precautions to ensurethat 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 F
Page 2 of5
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)ofthis Code of Conduct
and Ethics by County employees orother mental health contractors,or reportany activity that
they believe mayviolatethe standards ofthe Compliance Program,or anyother applicable
law,regulation,rule or guideline. Fresno Countyprohibitsretaliation against any person
making a report.Any person engaging inany form of retaliation willbe subject to disciplinary
or otherappropriate action bythe County. Contractormay report anonymously.
10. Consultwiththe ComplianceOfficerifyouhaveanyquestionsor areuncertain of any
ComplianceProgramstandard or any otherapplicablelaw, regulation, rule or guideline.
11.Immediately notifythe ComplianceOfficerifthey become ormaybecomean Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit F
Page 3of 5
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
Ihereby acknowledge that I have received,read and understand the Contractor Code of Conduct andEthics"l herDy:acknowledge that Ihave received training and information on the Fresno County Mental
Heatth CompHance 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 asa mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement.I further understand that anyliolatior>olSief Contractor Code of Conduct and Ethics or the Compliance Program .s a v.ola.onoCountypolicyandmayalsobeaviolationofapplicablelaws,regulations,rules or guidelines.Ifurther
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance ProgrammayresultinterminationofmyagreementwithFresnoCounty.I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print):f M\\oT-\IAi>il *M fl lb "1 ft i -
Discipline:•Psychiatrist •Psychologist •LCSW •LMFT
Signature :_JMJ^l^2 Date:Q^IOjlA
For Group or Organizational Providers
Group/Org.Name (print):_.
Employee Name(print):
Discipline:•Psychiatrist •Psychologist •LCSW D LMFT
•Other:__—
JobTitle(if differentfrom Discipline):
Signature:Date:/!-
Exhibit F
Page ^of 5"
FresnoCounty MentalHealthCompliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received,read and understand the Contractor Code of Conduct and
Ethics.I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof.I further agree to abide by the
Contractor Code of Conduct and Ethics, and allCompliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement.I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines.I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County.I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print):
Discipline: •Psychiatrist •Psychologist •LCSW •LMFT
Signature :Date : / /
For Group or Organizational Providers
Group/Org.Name (print):HE^'f ^6 UXf (O*^I tC
Employee Name (print):
Discipline: •Psychiatrist •Psychologist •LCSW •LMFT
Other:fO°-^'•£:**t £-£•e^M vNA£0 IC At U '1 '£Ar^Pc£.T7VtVWv!i
Job Title (if different from Discipline)
Signature:/\\~V \K L.X rw-^i c°i Z^f&
Exhibit F
Page 5 of5
Fresno Bounty Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledgethat I have received,read and understand the ContractorCode of Conduct and
Ethics.I herby acknowledge that I have received training and information onthe 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 contractorforFresno 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 alsobe a violation of applicable laws,regulations,rules or guidelines.I further
understand that violation of the Contractor Code of Conduct and Ethics orthe 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):Uf\fl{/1 (^r,r>pp/T
Disciplm&^O^^hiatristQ^sychologist •LCSW •LMFT
Signature:N^/""Date:5_/J3?i /3&S
For Group or Organizational Providers
Group/Org. Name (print):
Employee Name (print):
Discipline:Q Psychiatrist •Psychologist •LCSW •LMFT
•Other:
Job Title (if different from Discipline):
Signature:Date: / /_
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
D/B/A
Exhibit G
Page (of b
I.Identifying Information
Name of entity I ^»<,
Address (number, street)
9c v?(N UirH?
Qty State
CA
ZIP code
CLIAnombTCWmii
TaxpayerID""Tll»r'FIN1 Telephone number
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
byTitles 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
A
*'
a *r
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
relatedto each other, this must be reported under "Remarks."
B. Type of entity:
NAME
a Sole proprietorship
•Unincorporated Associations
ADDRESS
a Partnership
a Other (specify).
EIN
X Corporation
If the disclosing entity is a corporation,list names,addresses of the directors,and EINs for corporations
under "Remarks."
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 X
NAME ADDRESS PROVIDER NUMBER
Exhibit G
Paget 2of 4>
YES NO
IV.A.Has there been a change in ownership or control within the last year?o X
If yes, give date.
B.Do you anticipate anychangeof ownership or control within the year?.
If yes,when?
C.Do you anticipate filing for bankruptcy within the year?.
If yes,when?
V.Is the facility operated by a management company or leased in whole or part by another organization?..
If yes, give date of change in operations.
VI.Has there been a change in Administrator,Director of Nursing,or Medical Director within thelast year?.
VII.A.Is this facility chain affiliated?
(Ifyes, listname,address of corporation, and EIN.)
Address (number,name)City
a q;
a e<
a cfN
B.If the answer to question VILA,is NO,was the facility ever affiliated witha
(If yes, listname,address ofcorporation, and EIN.)
chain?Ay()
Name EIN
Address (number,name)City State ZIP code
Whoever knowingly and willfully makes orcauses 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 ofa 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)
fVn,rij iit
Signature
Remarks
ir^a-rt -v—~)0G-^\>
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I.Identifying Information
Name of entity
Exhibit G
Page3 of
Address (number stroei)
Z4ibi efcu^eoi'^e x>t
City
04
Stale
C
ZIP code
9^
[Taxpayer 10 numDer TQlar>none number
o,
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 ina 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
X
*
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
•^ct'Tf (AjG^T ZHtriC£ut<?c Citeu &
(\'Aj^Jvi^XC,CA-y*S21
B.Type of entity:
O Sole proprietorship
o Unincorporated Associations
3 Partnership
•Other (specify).
a Corporation
D.
If the disclosing entity is a corporation,list names,addresses ofthe directors,and EINs for corporations
under "Remarks."
Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example:sole proprietor,partnership,or members ofBoardof Directors)If yes,list names,addresses
of individuals,and provider numbers
NAME ADDRESS PROVIDER NUMBER
U>
IV.A. Has there been a change in ownership or control withinthe last year?.
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?.
If yes,when?
C. Do you anticipate filing for bankruptcy withinthe year?.
If yes,when?
V.Is the facility operated by a management company or leased inwhole or part by another organization?..
If yes, give date of change in operations.
VI.Has there been a change in Administrator,Director of Nursing, or Medical Director within the last year?.
VII.A.Is this facility chain affiliated?
(If yes,list name,address of corporation,and EIN.)
Address (number,name)City
B. If the answer to question VILA,is NO,was the facility ever affiliated with a chain?
(If yes,list name,address of corporation,and EIN.)
$o
Exhibit G
Pagef of k>
YES NO
a N6
a y
a f
a
Name EIN
Address (number,name)City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. Inaddition, knowingly and willfully failing to fullyand 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 orcontract withthe agency,as appropriate.
Name of authorized representative (typed)
^Vtpcorr L\)e^~/C c O
Signature
S/Zv/ZQ/*
Remarks
85/27/2815 20:25 0080000088
Exhibit G
Page 5 of 6
DISCLOSUREOF OWNERSHIP AND CONTROLINTEREST STATEMENT
I.Identifying Information
tiuna a nnlity
ON CALL TRANSPORTATION, INC.
D/BrA
•Addrew (number,aJrMti
1942 CROMWELL AVE.,CLOVIS CA 93611 ^CLOVIS j*CA 2JP«xk>
93611
;CLIAnumbof TfopsywiD nuirtw [QN)
83-0358112
T«JaphOrta m*rt#r
{ 559 )248-9100
II.Answer the following questions by checking "Yes"or "No."If anyofthe questions are answered "Yes,"list names and
addresses of Individuals or corporations under"Remarks"onpage2.Identify each item number tobe continued.
A.Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percentor moreinthe institution,organizations,or agencythat have been convicted ofa criminal
offenserelatedtothe involvement ofsuch personaor organizations inanyofthe programs established ,
by Titles XVIII,XIX,or XX?a »
YES NO
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?0
C. Arethere any individuals currentlyemployed bythe institution,agency, or organizationina managerial,
accounting, auditing, or similar capacity who were employed by the Institution's, organization's, or
agency's fiscalintermediaryorcarrier within the previous12 months?(Title XVIII providers only)0
A.List names,addresses for Individuals,or the EIN for organizations having direct or indirect ownershipor 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. Ifmore than one individual is reported and any of these persons are
related to each other,this must be reported under "Remarks."
i
NAME ADDRESS EIN
LINDA COOPER 1942 CROMWELL AVE.CLOViS CA
VINCE COOPER 1942 CROMWELL AVE.CLOVIS CA
S.Type ofentity:D Sole proprietorship •Partnership fi5 Corporation
•Unincorporated Associations D Other (specify)^
C. Ifthe 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/Medlcaid facilities?
.:o y
NAME ADDRESS PROVIDER NUMBER
05/27/2015 20:25 0000000000
Exhibit G
Page6 of6
YES NO
IV.A.Has there been a change in ownership orcontrol within the last year?0 V
If yes,give date.^
°r\
°\
B.Do you anticipate anychange ofownership orcontrol within the year?
If yes, when?
C.Do you anticipate filing for bankruptcy within the year?..
If yes, when?__
V.Is the facility operated by a management company or leased in whole or part by another organization?a i(
If yes,give dateof change in operations.
VI.Has there been a change in Administrator,Director of Nursing,or Medical Director within the last year?a \§
-°IVII.A.Is this facilitychain affiliated?
(If yes,list name,address of corporation,and EINT)
Andrew (nwnbe*.name)City 8w«
B.If theanswerto question VILA,Is NO,wasthe facility ever affiliated with a chain?
(If yes,list name,address of corporation,and EIN.)
Address (ftorttbor.name)
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement,may be
prosecuted under applicable federal orstate laws.In addition,knowingly and willfully tailing to fully and accurately disclose the
information requested may result in denial ofa request to participate or where the entity already participates,a termination of
itsagreementor contract wftft theagency, as appropriate.
5-3-7-15
Exhibit H
Page 1 of4
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 ofa personto provide the certification required below will not
necessarily result in denial of participation in this covered transaction.The prospective
participant shallsubmitan explanation of why itcannot provide the certification set out
below.The certification or explanation will be considered inconnection with the
department oragency's determination whether toenter into this transaction.However,
failure ofthe prospective primary participant to furnish a certification oran explanation
shall disqualify such person from participation inthis transaction.
3. The certification inthis clause is a material representation of fact upon which
reliance was placedwhenthe departmentoragency determined toenter into this
transaction. Ifitis 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 mayterminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written noticeto
the department or agency to whichthis proposal is submitted ifat any timethe
prospective primaryparticipantlearns 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 ofthe rules implementing ExecutiveOrder 12549. You may contact the
department or agency to which this proposalis beingsubmittedfor assistance in
obtaining a copy of those regulations.
6.Nothing contained inthe foregoing shall be construed to require establishment
ofa system ofrecords inorderto render in good faith the certification required by this
clause. The knowledge and information ofa participantis not required to exceed that
which is normally possessed bya prudent personinthe ordinary course ofbusiness
dealings.
CERTIFICATION
Exhibit H
Page2of 4
(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 byany 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 ora criminal
offense inconnection with obtaining,attemptingto obtain, or performing a public
(Federal,Stateor 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 falsestatements,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 anyofthe
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature:Jgj.(fy*^—Date:(JS^cH*
(Printed Name &Title)(Name ofAgency or
Company)
CERTIFICATION
Exhibit H
Pagejl of 4
(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:/ALa/A v(^C&O Date:'i f?c 77 Dl Ss>
(Printed Name &Title)(Name of Agency or
Company)
CERTIFICATION
Exhibit H
Page 4 of4
(1)The prospective primary participant certifies to the best of its knowledgeand belief,
that it, its owners,officers,corporate managers and partners:
(a) Are not presently debarred,suspended,proposed for debarment,declared
ineligible,or voluntarily excluded byany 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 inconnection with obtaining,attempting toobtain, or performing a public
(Federal,State or local)transaction or contract under a public transaction;violation of
Federal or State antitruststatutes or commission ofembezzlement, theft,forgery,
bribery,falsification or destructionofrecords,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 primaryparticipant is unable to certifyto any ofthe
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature:Date:
(Printed Name &Title)
5>-pq-asitr
O lXhHT^p^t^
(Name of Agency or
Company)
Exhibit I
Page 1 of 2
FRESNO COUNTY MENTAL HEALTH PLAN
Grievances and Incident Reporting
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
•The Incident Report mustbe completed for all incidents involving clients.Thestaff person
who becomes aware ofthe incident completesthis form,and the supervisorco-signs it.
• When more than one client is involved inan 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 I
Page 2 of 2
3.Preliminary findings:How did it happen?Sequence ofevents.Be specific.If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity:Nonexistent Q inconsequential Q consequential Q death [_]not applicable |_J unknown |_J
4.Response:a)corrective action,b)Plan of Action,c)other
Completed by (print name)_____
Completed by (signature)Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit J
Page 1 of2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"),must
disclose any self-dealing transactions that they are a party to while providing goods,performing
services,or both for the County.Aself-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is aparty 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 thatthe
board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions ofthe CorporationsCode.
(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 describethe nature ofthe self-dealing transactionyouare a partyto)
Exhibit J
Page 2 of 2
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5)Authorized Signature
Signature:Date: