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HomeMy WebLinkAbout32156Agreement No. 15-317 AGREEMENT This Agreement is made and entered into this i ~ th day of -:fu. ~ '-; , 2015, by and between the COUNTY OF FRESNO, a Political Subdivision ofthe State of California, hereinafter referred to as "COUNTY", and KINGS VIEW BEHAVIORAL HEALTH, whose address is 7170 North Financial Drive, Suite 110, Fresno, California, 93 720, hereinafter referred to as "CONTRACTOR." WI T N E S S E T H: WHEREAS, COUNTY, through its Department of Behavioral Health (DBH) is in need of a qualified agency to provide Senate Bill (SB) 82 Rural Mental Health Triage services in East and West cities in Fresno County as specified in this Agreement, to help reduce stigma and discrimination against mental illness and provide mental health triage services in a working partnership with rural first responders; and WHEREAS, COUNTY, through its DBH, is a Mental Health Plan (MHP) as defined in Title 9 ofthe California Code of Regulations (C.C.R.), Section 1810.226; and WHEREAS, CONTRACTOR is qualified and willing to provide said services pursuant to the terms and conditions of this Agreement. NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto agree as follows: 1. SERVICES A. CONTRACTOR(S) shall perform all services and fulfill all responsibilities as identified in Exhibit A "SB 82 Rural Mental Health Triage Scope of Work", attached hereto and by this reference incorporated herein ~d made part of this Agreement. B. This Agreement provides for Rural Triage services to East Fresno County and West Fresno County. CONTRACTOR shall collect, maintain and report all data for East and West Fresno County Rural Triage services independent of one another, including but not limited to: Medi- Cal billing, other insurance billing, and reports; staff schedules and reports; performance measures; monthly invoices and general ledgers; and other data as requested. C. It is acknowledged by all parties hereto that C~UNTY's DBH Contracts - 1 - COUN1Y OF FRESNO Fresno, CA Division unit shall monitor the SB 82 Rural Triage Program operated by CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement. D. CONTRACTOR shall participate in monthly, or as needed, workgroup meetings consisting of staff from COUNTY's DBH to discuss MHSA requirements, data reporting, training, policies and procedures, overall program operations and any problems or foreseeable problems that may arise. E. It is acknowledged that upon execution of this Agreement, or as indicated under Section Two (2) of this Agreement, CONTRACTOR shall provide SB 82 Rural Mental Health Triage Services, as identified and incorporated herein, in the rural East Fresno County cities of Selma, Sanger, Kingsburg, Fowler, Reedley, Orange Cove and Parlier; and in the rural West Fresno County cities of Firebaugh, Mendota, Kerman, San Joaquin, Huron, and Coalinga. It is further acknowledged that the service site for client records, Medi-Cal billing, and other billing requirements for both East and West County Rural Triage services is to be determined at a later date and approved by COUNTY's DBH Director or designee. Any change to CONTRACTOR's location of the service site must be made with thirty (30) days advance written notice to COUNTY's DBH Director or designee and only upon written approval from COUNTY's DBH Director or designee. F. CONTRACTOR shall maintain requirements as an organizational provider throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement. If for any reason this status is not maintained COUNTY may terminate this Agreement pursuant to Section Three (3) ofthis Agreement. G. CONTRACTOR agrees that prior to and while providing services under the terms and conditions ofthis Agreement, CONTRACTOR shall have staff hired and in place for program services and operations or COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement, in accordance with Section Three (3) of this Agreement. 2. TERM This Agreement shall become effective upon execution for East Fresno County and shall terminate on the 301h day of June, 2018. Ill - 2 - COUN1Y OF FRESNO Fresno, CA This Agreement shall become effective October 1, 2015, for West Fresno County and shall terminate on the 30th day of June, 2018. 3. TERMINATION A. Non-Allocation of Funds -The terms ofthis Agreement, and the services to be provided thereunder, are contingent on the approval of funds by the appropriating government agency. Should sufficient funds not be allocated, the services provided may be modified, or this Agreement terminated at any time by giving the CONTRACTOR thirty (30) days advance written notice. B. Breach of Contract -The COUNTY may immediately suspend or terminate this Agreement in whole or in part, where in the determination of the COUNTY there is: 1) An illegal or improper use of funds; 2) A failure to comply with any term of this Agreement; 3) A substantially incorrect or incomplete report submitted to the COUNTY; 4) Improperly performed service. In no event shall any payment by COUNTY constitute a waiver by COUNTY of any breach of this Agreement or any default which may then exist on the part of CONTRACTOR. Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or default. COUNTY shall have the right to demand of CONTRACTOR repayment to COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of COUNTY were not expended in accordance with the terms of this Agreement. CONTRACTOR shall promptly refund any such funds upon demand or, at COUNTY's option; such repayment shall be deducted from future payments owing to CONTRACTOR under this Agreement. C. Without Cause -Under circumstances other than those set forth above, this Agreement may be terminated by COUNTY, or CONTRACTOR, or COUNTY's DBH Director or designee, upon the giving ofthirty (30) days advance written notice of intent to terminate. CONTRACTOR may terminate with appropriate thirty (30) days advance written notice of intent to terminate transmitted by CONTRACTOR to COUNTY by Certified U.S. Mail, Return Receipt Requested, addressed to the office of COUNTY as follows: Ill - 3 - COUNTY OF FRESNO Fresno, CA 4. COMPENSATION Director (or designee) County of Fresno Department of Behavioral Health P.O. Box 45003 Fresno, CA 93718-9886 The maximum compensation amount under this Agreement for Mental Health Triage services in East Fresno County and West Fresno County combined for the period July 14, 2015, through June 30,2018, shall not exceed Seven Million Thirty-Six Thousand Six Hundred Forty-One and No/100 Dollars ($7,036,641.00). East Fresno County The maximum compensation amount under this Agreement for East Fresno County Triage Services for the period July 14, 2015, through June 30, 2018, for all funding and revenue streams collectively shall not exceed Three Million Nine Hundred Fifteen Thousand Eight Hundred Seventy-Seven and No/100 Dollars ($3,915,877.00). The maximum compensation amount under this Agreement for East Fresno County Triage Services for the period of July 14, 2015, through June 30, 2016, shall not exceed One Million Three Hundred Thousand Four Hundred Thirty-One and No/100 Dollars ($1,300,431.00). The maximum amount ofSB 82 funding under this Agreement shall not exceed Eight Hundred Forty-Nine Thousand Six Hundred Fifty-Three and No/100 Dollars ($849,653.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Four Hundred Fifty Thousand Seven Hundred Seventy-Eight and No/100 Dollars ($450,778.00) in Medi-Cal Federal Financial Participation (FFP) to offset CONTRACTOR's program costs. The maximum compensation amount under this Agreement for East Fresno County Triage Services for the period of July 1, 2016, through June 30, 2017, shall not exceed One Million Two Hundred Eighty-Eight Thousand One Hundred Twenty-Four and No/100 Dollars ($1 ,288,124.00). The maximum amount of SB 82 funding under this Agreement shall not exceed Eight Hundred Forty-Two Thousand One Hundred Twenty-Two and No/100 Dollars ($842,122.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to - 4 - COUNTY OF FRESNO Fresno, CA generate Four Hundred Forty-Six Thousand Two and No/100 Dollars ($446,002.00) in Medi-Cal FFP to offset CONTRACTOR's program costs. The maximum compensation amount under this Agreement for East Fresno County Triage Services for the period of July 1, 2017, through June 30, 2018, shall not exceed One Million Three Hundred Twenty-Seven Thousand Three Hundred Twenty-Two and No/100 Dollars ($1 ,327 ,322.00). The maximum amount of SB 82 funding under this Agreement shall not exceed Eight Hundred Sixty-Seven Thousand One Hundred Sixty-Eight and No/100 Dollars ($867,168.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Four Hundred Sixty Thousand One Hundred Fifty-Four and No/100 Dollars ($460,154.00) in Medi-Cal FFP to offset CONTRACTOR's program costs. West Fresno County The maximum compensation amount under this Agreement for West Fresno County Triage Services for the period October 1, 2015, through June 30, 2018, shall not exceed Three Million One Hundred Twenty Thousand Seven Hundred Sixty-Four and No/100 Dollars ($3,120,764.00). The maximum compensation amount under this Agreement for West Fresno County Triage Services for the period of October 1, 2015, through June 30,2016, shall not exceed Nine Hundred Eight Thousand Four Hundred Twenty-Two and No/100 Dollars ($908,422.00). The maximum amount of Public Safety Realignment funding under this Agreement in this term shall not exceed Three Hundred Fifty Thousand and No/100 Dollars ($350,000.00). The maximum amount of Mental Health Services Act (MHSA) funding under this Agreement in this term shall not exceed One Hundred Ninety-Eight Thousand Four Hundred Fifty-Five and No/100 Dollars ($198,455.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Three Hundred Fifty-Nine Thousand Nine Hundred Sixty-Seven and No/100 Dollars ($359,967.00) in Medi-Cal FFP in this term to offset CONTRACTOR's program costs. The maximum compensation amount under this Agreement for West Fresno County Triage Services for the period of July 1, 2016, through June 30, 2017, shall not exceed One Million Eighty-Nine Thousand Five Hundred Fifty and No/100 Dollars ($1,089,550.00). The maximum amount of Public Safety Realignment funding under this Agreement in this term shall not exceed -5 -COUNTY OF FRESNO Fresno, CA Three Hundred Fifty Thousand and No/100 Dollars ($350,000.00). The maximum amount ofMHSA funding under this Agreement in this term shall not exceed Two Hundred Ninety-Three Thousand Five Hundred Forty-Eight and No/100 Dollars ($293,548.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Four Hundred Forty-Six Thousand Two and No/100 Dollars ($446,002.00) in Medi-Cal FFP in this term to offset CONTRACTOR's program costs. In the event that Public Safety Realignment funds are not allocated for this term, MHSA funding will be increased by Three Hundred Fifty Thousand and No/100 Dollars ($350,000.00), bringing the maximum amount ofMHSA funding under this Agreement in this term to Six Hundred Forty-Three Thousand Five Hundred Forty-Eight and No/1 00 Dollars ($643,548.00); and reducing the maximum amount of Public Safety Realignment funding to Zero and No/100 Dollars ($0.00). The maximum compensation amount under this Agreement for West Fresno County Triage Services for the period of July 1, 2017, through June 30, 2018, shall not exceed One Million One Hundred Twenty-Two Thousand Seven Hundred Ninety-Two and No/100 Dollars ($1,122,792.00). The maximum amount of Public Safety Realignment funding under this Agreement in this term shall not exceed Three Hundred Fifty Thousand and No/100 Dollars ($350,000.00). The maximum amount of MHSA funding under this Agreement in this term shall not exceed Three Hundred Twelve Thousand Six Hundred Thirty-Eight and No/100 Dollars ($312,638.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Four Hundred Sixty Thousand One Hundred Fifty-Four and No/100 Dollars ($460,154.00) in Medi-Cal FFP in this term to offset CONTRACTOR's program costs. In the event that Public Safety Realignment funds are not allocated for this term, MHSA funding will be increased by Three Hundred Fifty Thousand and No/100 Dollars ($350,000.00), bringing the maximum amount ofMHSA funding under this Agreement in this term to Six Hundred Sixty-Two Thousand Six Hundred Thirty-Eight and No/100 Dollars ($662,638.00); and reducing the maximum amount ofPublic Safety Realignment funding to Zero and No/100 Dollars ($0.00). Ill The maximum amounts paid to the CONTRACTOR for East and West Fresno County - 6 - COUNTY OF FRESNO Fresno,CA Rural Mental Health Triage services identified in the Agreement are stated in Exhibit C "East Budgets", and Exhibit C "West Budgets", attached hereto and by this reference incorporated herein. A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive compensation based upon actual expenditures incurred by CONTRACTOR for monthly program costs, in accordance with the budgets identified in Exhibit C "East Budget" and Exhibit C "West Budget". B. If CONTRACTOR fails to generate the Medi-Cal FFP set forth hereinabove, the COUNTY shall not be obligated to pay the difference between these estimated amounts and the actual amounts generated. It is further understood by COUNTY and CONTRACTOR that any Medi-Cal FFP generated above the amounts stated herein will be used to directly offset the COUNTY's contribution of SB 82 funds identified in Exhibit C "East Budget" and Exhibit C "West Budget." The offset of funds will also be clearly identified in monthly invoices received from CONTRACTOR as further described in Section Five (5) of this Agreement. Travel shall be reimbursed based on actual expenditures and mileage reimbursement shall be at CONTRACTOR's adopted rate per mile, no to exceed the Internal Revenue Service (IRS) published rate. Payment shall be made upon certification or other proof satisfactory to COUNTY's DBH that services have actually been performed by CONTRACTOR as specified in this Agreement. C. It is understood that all expenses incidental to CONTRACTOR performance of services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for further compensation. D. Except as provided below regarding State payment delays, payments shall be made by COUNTY to CONTRACTOR in arrears, for services provided during the preceding month, within forty-five (45) days after the date of receipt and approval by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made after receipt and -7 -COUNTY OF FRESNO Fresno,CA ______ I verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as identified in Exhibit C "East Budget" and Exhibit C "West Budget", in the performance ofthis Agreement and shall be documented to COUNTY on a monthly basis by the fifteenth (15 1h) of the month following the month of said expenditures. The parties acknowledge that the CONTRACTOR will be performing hiring, training, and credentialing of staff, configuring the facility and office space, and obtaining site certification from the COUNTY Mental Health Plan. CONTRACTOR shall submit to the COUNTY by the fifteenth (15th) of each month a detailed general ledger (GL) itemizing costs incurred in the previous month. Failure to submit GL reports and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until there is compliance, as further described in Section Five (5) herein. E. COUNTY shall not be obligated to make any payments under this Agreement if the request for payment is received by COUNTY more than sixty (60) days after this Agreement has terminated or expired. All final claims, including actual cost per unit, and/or any final budget modification requests shall be submitted by CONTRACTOR within sixty (60) days following the final month of service for which payment is claimed. No action shall be taken by COUNTY on claims submitted beyond the sixty ( 60) day closeout period. Any compensation which is not expended by CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to COUNTY. F. The services provided by CONTRACTOR under this Agreement are funded in whole or in part by the State of California. In the event that funding for these services is delayed by the State Controller, COUNTY may defer payment to CONTRACTOR. The amount of the deferred payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller's delay of payment to COUNTY plus forty-five ( 45) days. G. CONTRACTOR shall be held financially liable for any and all future disallowances/audit exceptions due to CONTRACTOR's deficiency discovered through the State audit Process and COUNTY utilization review during the course of this Agreement. At COUNTY's - 8 - COUN1Y OF FRESNO Fresno,CA election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive reimbursement for any units of services rendered that are disallowed or denied by the Fresno County Mental Health Plan utilization review process or through the Department of Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients. H. Any compensation which is not expended by CONTRACTOR pursuant to the terms and conditions of this Agreement shall be remitted to COUNTY within sixty ( 60) days of receipt and verification of inappropriate expenditures by COUNTY's DBH Director, or designee. I. Any compensation which is not consumed by expenditures of CONTRACTOR by the expiration or termination of this Agreement shall automatically revert to COUNTY. 5. INVOICING A. CONTRACTOR shall invoice COUNTY in arrears by the fifteenth (15th) day of each month for the prior month's actual services rendered to DBHinvoices@co.fresno.ca.us. After CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for payment, certify the expenditure, and submit electronic claiming billing directly into COUNTY's billing system (AVATAR) for the DHCS reimbursements for all clients, including those eligible for Medi-Cal as well as those that are not eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. COUNTY must pay CONTRACTOR before submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible clients. B. At the discretion of COUNTY's DBH Director, or designee, if an invoice is incorrect or is otherwise not in proper form or substance, COUNTY's DBH Director, or designee, shall have the right to withhold payment as to only that portion of the invoice that is incorrect or improper after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a period of ninety (90) days after notification of an incorrect or improper invoice. If after the ninety (90) day period, the invoice(s) is still not corrected to COUNTY DBH's satisfaction, COUNTY's DBH Director, or designee, may elect to terminate this Agreement, pursuant to the termination provisions stated in Section Three (3) of this Agreement. In addition, for invoices received ninety (90) days after the expiration of each term of this Agreement or termination of this - 9 - COUNTY OF FRESNO Fresno, CA Agreement, at the discretion of COUNTY's DBH Director, or designee, COUNTY's DBH shall have the right to deny payment of any additional invoices received. C. Monthly invoices shall include a client roster, identifying volume reported by payer group clients served (including third party payer of services) by month and year-to-date, including percentages. D. CONTRACTOR shall submit monthly invoices and general ledgers that itemize the line item charges for monthly program costs (per applicable budget, as identified in Exhibit C "East Budget" and Exhibit C "West Budget), including the cost per unit calculation based on clients served within that month, and excluding lobbying costs. The invoices and general ledgers will serve as tracking tools to determine if CONTRACTOR's program costs are in accordance with its budgeted cost, and cost per unit negotiated by service modes compared to actual cost per unit, as set forth in Exhibit C "East Budget" and Exhibit C "West Budget". The actual cost per unit will be based upon total costs and total units of service. It will also serve for the COUNTY to certify the public funds expended for purposes of claiming federal reimbursement for the cost of Medicaid services and activities. CONTRACTOR shall remit to COUNTY on a quarterly basis, a summary report of total operational costs and volume of service unit to report the actual costs per unit compared to the negotiated rate, as identified in Exhibit C "East Budget" and Exhibit C "West Budget", to report interim cost per unit. The quarterly reports will be used by COUNTY to ensure compliance with federal reimbursements certified public expenditures. E. CONTRACTOR must report all third party collections from other funding sources such as Medicare, private insurance, client private pay or any other third party. COUNTY expects the invoice for reimbursement to equal the amount due CONTRACTOR less any funding sources not eligible for federal reimbursement. F. CONTRACTOR will remit annually within ninety (90) days from June 30, a schedule to provide the required information on published charges (PC) for all authorized services. The published charge listing will serve as a source document to determine the CONTRACTOR's usual and customary charge prevalent in the public mental health sector that is used to bill the general public, insurers or other non-Medi-Cal third party payers during the course of business operations. -10 -COUNTY OF FRESNO Fresno, CA G. CONTRACTOR shall submit monthly staffing reports that identify all direct service and support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking tool to determine if CONTRACTOR's program is staffed according to the Agreement requirements. H. CONTRACTOR must maintain such financial records for a period of seven (7) years or until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for any disallowances related to inadequate documentation. I. CONTRACTOR is responsible for collection and managing data in a manner to be determined by DHCS and the Mental Health Plan in accordance with applicable rules and regulations. COUNTY electronic billing system is a critical source of information for purposes of monitoring and obtaining reimbursement. CONTRACTOR must attend COUNTY's Business Office training on equipment reporting for assets, intangible and sensitive minor assets, Avatar claiming module and related cost reporting. J. CONTRACTOR shall submit electronic billing for services directly into COUNTY's billing module (AVATAR) within ten (10) calendar days from the date services were rendered. DHCS' FFP reimbursement for Medi-Cal specialty mental health services is based on public expenditures certified by the CONTRACTOR. CONTRACTOR must submit a signed certified public expenditure report, with each respective monthly invoice. DHCS expects the claim for reimbursement to equal the amount the COUNTY paid the CONTRACTOR for the service rendered less any funding sources not eligible for Federal reimbursement. K. CONTRACTOR must provide all necessary data to allow the COUNTY to bill Medi-Cal, and any other third-party source, for services and meet State and Federal reporting requirements. The necessary data can be provided by a variety of means, including but not limited to: 1) direct data entry into COUNTY's information system; 2) providing an electronic file compatible with COUNTY's information system; or 3) integration between COUNTY's information system and CONTRACTOR's information system(s). L. If a Medi-Cal client has dual coverage, such as other health coverage (OHC) or Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a -11 -COUN1Y OF FRESNO Fresno, CA payment/denial or have validation of claiming with no response ninety (90) days after the claim was mailed before the service can be entered into AVA TAR. CONTRACTOR must report all third party collections for Medicare, third party or client pay or private pay in each monthly invoice and in the cost report that is required to be submitted. A copy of explanation ofbenefits or CSM 1500 is required as documentation. CONTRACTOR must comply with all laws and regulations governing Medicare program, including, but not limited to: 1) the requirement ofthe Medicare Act, 42 U.S.C. section 1395 et seq; and 2) the regulation and rules promulgated by the Centers for Medicare and Medicaid Services as they relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for compliance as of the effective date of each federal, state or local law or regulation specified. M. Data entry shall be the responsibility of the CONTRACTOR. The data for billing must be reconciled by the CONTRACTOR to the monthly invoices submitted for payment. COUNTY shall monitor the number and dollar amount of services entered into AVATAR. Any and all audit exceptions resulting from the provision and billing of Medi-Cal services by CONTRACTOR shall be the sole responsibility of the CONTRACTOR. CONTRACTOR will comply with all applicable policies, procedures, directives and guidelines regarding the use of COUNTY's billing system. N. Medi-Cal Certification and Mental Health Plan Compliance CONTRACTOR will establish and maintain Medi-Cal certification or become certified within ninety (90) days of the effective date of this Agreement through COUNTY to provide reimbursable services to Medi-Cal eligible adult clients. In addition, CONTRACTOR shall work with the COUNTY's DBH Managed Care and Business Office to execute the process if not currently certified by COUNTY for credentialing of staff. During this process, the CONTRACTOR will obtain a legal entity number established by the DHCS, a requirement for maintaining organizational provider status throughout the term of this Agreement. CONTRACTOR will be required to become Medi-Cal certified prior to providing services to Medi-Cal eligible clients and seeking reimbursement in COUNTY's billing system. CONTRACTOR will not be reimbursed by COUNTY for any Medi-Cal services rendered prior to certification. -12 -COUN1Y OF FRESNO Fresno, CA Medi-Cal billing shall be in accordance with the Mental Health Plan. CONTRACTOR must comply with the "Fresno County Mental Health Plan Compliance Program and Code of Conduct" set forth in Exhibit D, attached hereto and incorporated herein by reference and made part of this Agreement. Medi-Cal can be billed for direct specialty mental health services of unlicensed staff as long as the individual is approved as an organizational provider by the Mental Health Plan, is supervised by licensed staff, works within his/her scope and only bills Medi-Cal for allowable specialty mental health services. It is understood that each claim is subject to audit for compliance with Federal and State regulations, and that COUNTY may be making payments in advance of said review. In the event that a Medi-Cal billable service is disapproved, COUNTY may, at its sole discretion, withhold compensation or set off from other payments due the amount of said disapproved services. CONTRACTOR shall be responsible for audit exceptions to ineligible dates of services or incorrect application of utilization review requirements. 6. INDEPENDENT CONTRACTOR In performance of the work, duties, and obligations assumed by CONTRACTOR under this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an independent contractor, and shall act in an independent capacity and not as an officer, agent, servant, employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no right to control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and function. However, COUNTY shall retain the right to administer this Agreement so as to verify that CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules and regulations, if any, of governmental authorities having jurisdiction over matters which are directly or indirectly the subject of this Agreement. Because of its status as an independent contractor, CONTRACTOR shall have absolutely no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees -13 -COUN1Y OF FRESNO Fresno, CA ------i all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all matters relating to payment of CONTRACTOR's employees, including compliance with Social Security, withholding, and all other regulations governing such matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be providing services to others unrelated to the COUNTY or to this Agreement. 7. MODIFICATION Any matters of this Agreement may be modified from time to time by the written consent of all the parties without, in any way, affecting the remainder. Notwithstanding the above, changes to line items in the budgets, attached hereto as Exhibit C "East Budget" and Exhibit C "West Budget", which do not exceed ten percent (10%) of the total maximum compensation payable to CONTRACTOR, and changes to the volume of units of services/types of service units to be provided as set forth in Exhibit C "East Budget" and Exhibit C "West Budget", may be made with the written approval of COUNTY's DBH Director or designee and CONTRACTOR. Said budget line item and service volume/types of service units changes shall not result in any change to the maximum compensation amount payable to CONTRACTOR, as stated herein. 8. NON-ASSIGNMENT Neither party shall assign, transfer or subcontract this Agreement nor their rights or duties under this Agreement without the prior written consent of the other party. 9. HOLD-HARMLESS CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request, defend the COUNTY, its officers, agents and employees from any and all costs and expenses, including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all costs and expenses, including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or corporation who may be injured or damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or employees under this Agreement. -14 -COUNTY OF FRESNO Fresno, CA CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local audit exceptions resulting from noncompliance herein on the part of the CONTRACTOR. 10. INSURANCE Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the following insurance policies throughout the term of this Agreement: Ill A. Commercial General Liability Commercial General Liability Insurance with limits of not less than One Million Dollars ($1 ,000,000) per occurrence and an annual aggregate of Two Million Dollars ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific coverage including completed operations, product liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire legal liability or any other liability insurance deemed necessary because of the nature of the Agreement. B. Automobile Liability Comprehensive Automobile Liability Insurance with limits for bodily injury of not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five Hundred Thousand Dollars ($500,000) per accident and for property damages of not less than Fifty Thousand Dollars ($50,000), or such coverage with a combined single limit of One Million Dollars ($1 ,000,000). Coverage should include owned and non-owned vehicles used in connection with this Agreement. C. Real And Personal Property CONTRACTOR shall maintain a policy of insurance for all risk personal property coverage which shall be endorsed naming the County of Fresno as an additional loss payee. The personal property coverage shall be in an amount that will cover the total of the COUNTY purchased and owned property, at a minimum, as discussed in Section Twenty-Seven (27) of this Agreement. D. All Risk Property Insurance CONTRACTOR will provide property coverage for the full replacement value of COUNTY's Personal Property in the possession of CONTRACTOR and/or used in the execution of this Agreement. COUNTY will be identified on an appropriate certificate of insurance as the certificate holder and will be named as an Additional Loss Payee on the Property Insurance Policy. -15 -COUNTY OF FRESNO Fresno, CA E. Fire Insurance and Extended Coverage CONTRACTOR shall add COUNTY as an additional Loss Payee thereon. F. Professional Liability If CONTRACTOR(S) employs licensed professional staff (e.g. Ph.D., R.N., L.C.S.W., L.M.F.T.) in providing services, Professional Liability Insurance with limits of not less than One Million Dollars ($1 ,000,000) per occurrence, Three Million Dollars ($3,000,000) annual aggregate. CONTRACTOR agrees that it shall maintain, at its sole expense, in full force and effect for a period of three (3) years following the termination of this Agreement, one or more policies of professional liability insurance with limits of coverage as specified herein. G. Worker's Compensation A policy of Worker's Compensation Insurance as may be required by the California Labor Code. CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance naming the County of Fresno, its officers, agents, and employees, individually and collectively, as additional insured, but only insofar as the operations under this Agreement are concerned. Such coverage for additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained by the COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance provided under the CONTRACTOR's 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 signs this Agreement, CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, Mental Health Services Act, 313 3 N. Millbrook Ave., Fresno, California, 93 703, Attention: Mental Health Contracts Division, stating that such insurance coverage's have been obtained and are in full force; that the County of Fresno, its officers, agents and employees will not be 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, but only insofar as the 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 the -16 -COUN1Y OF FRESNO Fresno, CA COUNTY, its officers, agents and employees, shall be excess only and not contributing with insurance provided under the CONTRACTOR's policies herein; and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days advance, written notice given to COUNTY. In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement upon the occurrence of such event. All policies shall be with admitted insurers licensed to do business in the State of California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of A FSC VII or better. 11. LICENSES/CERTIFICATES Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR's staff shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States of America, State of California, the County ofFresno, and any other applicable governmental agencies. CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions irrespective ofthe pendency of any appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR's staff shall comply with all applicable laws, rules or regulations, as may now exist or be hereafter changed. 12. RECORDS CONTRACTOR shall maintain records in accordance with Exhibit E, "Documentation Standards for Client Records", attached hereto and by this reference incorporated herein and made part of this Agreement. During site visits, COUNTY shall be allowed to review records of services provided, including the goals and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives. 13. REPORTS A. Cost Report-CONTRACTOR agrees to submit a complete and accurate detailed cost report on an annual basis for each fiscal year ending June 30th in the format prescribed by -17 -COUNTY OF FRESNO Fresno,CA the DHCS for the purposes of Short Doyle Medi-Cal reimbursements and total costs for programs. Each cost report will be the source document for several phases of settlement with the DHCS for the purposes of Short Doyle Medi-Cal reimbursement. CONTRACTOR shall report costs under their approved legal entity number established during the Medi-Cal certification process. The information provided applies to CONTRACTOR for program related costs for services rendered to Medi-Cal and non Medi-Cal. The CONTRACTOR will remit a schedule to provide the required information on published charges (PC) for all authorized services. The report will serve as a source document to determine their usual and customary charge prevalent in the public mental health sector that is used to bill the general public, insurers or other non-Medi-Cal third party payers during the course of business operations. CONTRACTOR must report all collections for Medi-Cal/Medicare services and collections. CONTRACTOR shall also submit with each cost report a copy of the CONTRACTOR's general ledger that supports revenues and expenditures. CONTRACTOR must also include a reconciled detailed report of the total units of services rendered under this Agreement compared to the units of services entered by CONTRACTOR into COUNTY's data system. Cost reports must be submitted to the COUNTY as a hard copy with a signed cover letter and electronic copy of the completed DHCS cost report form along with requested support documents following each fiscal year ending June 30th. During the month of September of each year this Agreement is effective, COUNTY will issue instructions of the annual cost report which indicates the training session, DHCS cost report template worksheets, and deadlines to submit as determined by the State annually. Remit the hard copies of the cost reports to County of Fresno, Attention: Cost Report Team, P.O. Box 45003, Fresno, CA 93718. Remit the electronic copy or any inquiries to DBHcostreportteam@co.fresno.ca.us. All cost reports must be prepared in accordance with Generally Accepted Accounting Principles (GAAP) and Welfare and Institutions Code§§ 5651(a)(4), 5664(a), 5705(b)(3) and 5718(c). Unallowable costs such as lobby or political donations must be deducted on the cost report and invoice reimbursements. ' If the CONTRACTOR does not submit the cost report by the deadline, including any extension period granted by the COUNTY, the COUNTY may withhold payments of pending -18 -COUNTY OF FRESNO Fresno, CA invoicing under compensation until the cost report has been submitted and clears COUNTY desk audit for completeness. B. Settlements with 'state Department of Health Care Services (DHCS) During the term of this Agreement and thereafter, COUNTY and CONTRACTOR agree to settle dollar amounts disallowed or settled in accordance with DHCS and COUNTY audit settlement findings related to the Medi-Cal and realignment reimbursements. CONTRACTOR will participate in the several phases of settlements between COUNTY, CONTRACTOR and DHCS. The phases of initial cost reporting for settlement according to State reconciliation of records for paid Medi-Cal services and audit settlement are: DHCS audit: 1) initial cost reporting-after an internal review by COUNTY, the COUNTY files cost report with DHCS on behalf of the CONTRACTOR's legal entity for the fiscal year; 2) Settlement -State reconciliation of records for paid Medi-Cal services, approximately eighteen (18) to thirty-six (36) months following the State close of the fiscal year, DHCS will send notice for any settlement under this provision will be sent to the COUNTY; and 3) Audit Settlement-DHCS audit. After final reconciliation and settlement, COUNTY and/or DHCS may conduct a review of medical records, cost report along with support documents submitted to COUNTY in initial submission to determine accuracy and may disallow cost and/or unit of service reported on the CONTRACTOR's legal entity cost report. COUNTY may choose to appeal and therefore reserves the right to defer payback settlement with CONTRACTOR until resolution of the appeal. DHCS Audits will follow federal Medicaid procedures for managing overpayments. If at the end of the Audit Settlement, the COUNTY determines that it overpaid the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related overpayment back to the COUNTY. Funds owed to COUNTY will be due within forty-five (45) days of notification by the COUNTY, or COUNTY shall withhold future payments until all excess funds have been recouped by means of an offset against any payments then or thereafter owing to CONTRACTOR under this or any other Agreement. C. Monthly Reports-CONTRACTOR shall submit a monthly report to the County -19 -COUNTY OF FRESNO Fresno, CA that will include, but not be limited to dollars billed for Medi-Cal and MHSA (non Medi-Cal) clients; actual expenses; the number of clients served/anticipated to be served; utilization of services by clients; and staff composition. This report will be due within thirty (30) days after the last day of the previous month or payments may be delayed. CONTRACTOR will utilize a computerized tracking system with which outcome measures and other relevant client data, such as demographics, will be maintained. D. Outcome Reports-CONTRACTOR shall submit to COUNTY's DBH service outcome reports as requested by DBH. Outcome reports and outcome requirements are subject to change at COUNTY DBH's discretion. E. Additional Reports-CONTRACTOR shall also furnish to COUNTY such statements, records, reports, data, and other information as COUNTY's DBH may request pertaining to matters covered by this Agreement. In the event that CONTRACTOR fails to provide such reports or other information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments until there is compliance. In addition, CONTRACTOR shall provide written notification and explanation to COUNTY within five (5) days of any funds received from another source to conduct the same services covered by this Agreement. F. Progress Report Updates-CONTRACTOR shall complete Progress Report updates according to DHCS regulations, in the form set forth in Exhibit F and Exhibit Fa, attached hereto and by this reference incorporated herein and made part of this Agreement. CONTRACTOR shall submit the required progress updates, as shown in Exhibit F and Exhibit Fa, to COUNTY's DBH Mental Health Contracts Division for review. CONTRACTOR shall submit to COUNTY's DBH by the Fifteenth (15th) of each month all monthly activity, outcome and budget reports for the preceding month. CONTRACTOR shall also provide records of rents collected from each client and include the client's name, date ofbirth and social security number. All data transmitted must be in strict conformance with Section Nineteen (19) and Section Twenty (20) of this Agreement. 14. MONITORING CONTRACTOR(S) agrees to extend to COUNTY's staff, COUNTY's DBH Director -20 -COUNTY OF FRESNO Fresno, CA and the DHCS, or their designees, the right to review and monitor records, program or procedures, at any time, in regard to clients, as well as the overall operation of CONTRACTOR's program, in order to ensure compliance with the terms and conditions of this Agreement. 15. REFERENCES TO LAWS AND RULES In the event any law, regulation, or policy referred to in this Agreement is amended during the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of such amendment. 16. COMPLIANCE WITH STATE REQUIREMENTS CONTRACTOR recognizes that COUNTY operates its mental health programs under an agreement with DHCS, and that under said agreement the State imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall adhere to all State requirements, including those identified in Exhibit G, "State Mental Health Requirements", attached hereto and by this reference incorporated herein and made part of this Agreement. 17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS CONTRACTOR shall be required to maintain organizational provider certification by Fresno County. CONTRACTOR must meet Medi-Cal organization provider standards as listed in Exhibit H, "Medi-Cal Organizational Provider Standards", attached hereto and by this reference incorporated herein and made part of this Agreement. It is acknowledged that all references to Organizational Provider and/or Provider in Exhibit H shall refer to CONTRACTOR. In addition, CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health Plan as described in Exhibit I, "Fresno County Mental Health Plan Grievances and Incident Reporting", attached hereto and by this reference incorporated herein. CONTRACTOR shall also file an incident report for all incidents involving clients, following the Protocol for Completion of Incident Report and using the "Incident Report Worksheet" both identified in Exhibit I, attached hereto and by this reference incorporated herein and made part of this Agreement, or a protocol and worksheet presented by CONTRACTOR that is accepted by County's DBH Director, or designee. 18. CONFIDENTIALITY All services performed by CONTRACTOR under this Agreement and any information -21 -COUNTY OF FRESNO Fresno, CA CONTRACTOR creates, receives, or maintains pertaining to protected health information shall be in strict conformance with all applicable Federal, State of California and/or local laws and regulations relating to confidentiality. 19. HEALTH INSURANCE PORTABILITY AND ACCOUNT ABILITY ACT COUNTY and CONTRACTOR each consider and represent themselves as covered entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-191(HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law. COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is only for treatment, payment, and health care operations. COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of PHI pursuant to the Agreement in compliance with HIP AA, the Health Information Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder by the U.S. Department ofHealth and Human Services (HIPAA Regulations) and other applicable laws. As part of the HIP AA Regulations, the Privacy Rule and the Security Rule require CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) ofthe Code of Federal Regulations (CFR). 20. DATA SECURITY For the purpose of preventing the potential loss, misappropriation or inadvertent access, viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into a contractual relationship with the COUNTY for the purpose of providing services under this Agreement must employ adequate data security measures to protect the confidential information provided to CONTRACTOR by the COUNTY, including but not limited to the following: Ill Ill -22 -COUNTY OF FRESNO Fresno, CA A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices CONTRACTOR may not connect to COUNTY networks via personally-owned mobile, wireless or handheld devices, unless the following conditions are met: 1) CONTRACTOR has received authorization by COUNTY for telecommuting purposes; 2) Current virus protection software is in place; 3) Mobile device has the remote wipe feature enabled; and 4) A secure connection is used. B. CONTRACTOR-Owned Computers or Computer Peripherals CONTRACTOR may not bring CONTRACTOR-owned computers or computer peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is approved to be transferred, data must be stored on a secure server approved by the COUNTY and transferred by means of a Virtual Private Network (VPN) connection, or another type of secure connection. Said data must be encrypted. C. COUNTY -Owned Computer Equipment CONTRACTOR, including its subcontractors and employees, may not use COUNTY computers or computer peripherals on non-COUNTY premises without prior authorization from the COUNTY's Chieflnformation Officer, and/or designee(s). D. CONTRACTOR may not store COUNTY's private, confidential or sensitive data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted. E. CONTRACTOR shall be responsible to employ strict controls to ensure the integrity and security of COUNTY's confidential information and to prevent unauthorized access, viewing, use or disclosure of data maintained in computer files, program documentation, data processing systems, data files and data processing equipment which stores or processes COUNTY data internally and externally. Ill Ill -23 -COUNTY OF FRESNO Fresno, CA F. Confidential client information transmitted to one party by the other by means of electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128 BIT or higher. Additionally, a password or pass phrase must be utilized. G. CONTRACTOR is responsible to immediately notify COUNTY of any violations, breaches or potential breaches of security related to COUNTY's confidential information, data maintained in computer files, program documentation, data processing systems, data files and data processing equipment which stores or processes COUNTY data internally or externally. H. COUNTY shall provide oversight to CONTRACTOR's response to all incidents arising from a possible breach of security related to COUNTY's confidential client information provided to CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be responsible for all costs incurred as a result of providing the required notification. 21. NON-DISCRIMINATION During the performance of this Agreement CONTRACTOR shall not unlawfully discriminate against any employee or applicant for employment, or recipient of services, because of race, religion, color, national origin, ancestry, physical disability, medical condition, marital status, age or gender, pursuant to all applicable State of California and Federal statutes and regulations. 22. TAX EQUITY AND FISCALRESPONSIBILITY ACT To the extent necessary to prevent disallowance of reimbursement under section 1861(v) (1) (I) ofthe Social Security Act, (42 U.S.C. § 1395x, subd. (v)(l)[I]), until the expiration offour (4) years after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon written request of the Secretary of the United States Department of Health and Human Services, or upon request of the Comptroller General of the United States General Accounting Office, or any of their duly authorized representatives, a copy of this Agreement and such books, documents, and records as are necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value -24 -COUNTY OF FRESNO Fresno, CA or cost ofTen Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such Agreement shall contain a clause to the effect that until the expiration of four ( 4) years after the furnishing of such services pursuant to such subcontract, the related organizations shall make available, upon written request of the Secretary of the United States Department of Health and Human Services, or upon request of the Comptroller General of the United States General Accounting Office, or any of their duly authorized representatives, a copy of such subcontract and such books, documents, and records of such organization as are necessary to verify the nature and extent of such costs. 23. SINGLE AUDIT CLAUSE If any CONTRACTOR expends Seven Hundred FiftyThousand Dollars ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in accordance with the requirements of the Single Audit Standards as set forth in Office of Management and Budget (OMB) Circular A-133. CONTRACTOR shall submit said audit and management letter to COUNTY. The audit must include a statement of findings or a statement that there were no findings. If there were negative findings, CONTRACTOR shall include a corrective action plan signed by an authorized individual. CONTRACTOR agrees to take action to correct any material non-compliance or weakness found as a result of such audit. Such audits shall be delivered to COUNTY's DBH Business Office for review within nine (9) months ofthe end of any fiscal year in which funds were expended and/or received for the program. Failure to perform the requisite audit functions as required by this Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY's option, contracting with a public accountant to perform said audit, or may result in the inability of COUNTY to enter into future agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility of CONTRACTOR. A. A single audit report is not applicable if CONTRACTOR's Federal contracts do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR's only funding is through Medi-Cal. If a single audit is not applicable, a program audit must be performed and a program audit report with management letter shall be submitted by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR's solvency. -25 -COUNTY OF FRESNO Fresno,CA Said audit reports shall be delivered to COUNTY's DBH Business Office for review no later than nine (9) months after the close of the fiscal year in which the funds supplied through this Agreement are expended. Failure to comply with this Act may result in COUNTY performing the necessary audit tasks or contracting with a qualified accountant to perform said audit. All audit costs related to this Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or weakness found as a result of such audit. Audit work performed by COUNTY under this Section shall be billed to the CONTRACTOR at COUNTY's cost, as determined by COUNTY's Auditor-Controller/ Treasurer-Tax Collector. B. CONTRACTOR shall make available all records and accounts for inspection by COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a period of at least three (3) years following final payment under this Agreement or the closure of all other pending matters, whichever is later. 24. COMPLIANCE CONTRACTOR agrees to comply with COUNTY's Contractor Code of Conduct and Ethics and the COUNTY's Compliance Program in accordance with Exhibit D. Within thirty (30) days of entering into this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR's employees, agents and subcontractors providing services under this Agreement certify in writing, that he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall ensure that within thirty (30) days ofhire, all new employees, agents and subcontractors providing services under this Agreement shall certify in writing that he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR understand that the promotion of and adherence to the code of Conduct and Ethics is an element in evaluating the performance of CONTRACTOR and its employees, agents and subcontractors. Within thirty (30) days of entering into this Agreement, and annually thereafter, all employees, agent and subcontractors providing services under this Agreement shall complete general compliance training and appropriate employees, agents and subcontractors shall complete -26 -COUN'IY OF FRESNO Fresno, CA documentation and billing or billing/reimbursement training. All new employees, agents and subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual required to attend training shall certify in.writing that he or she has received the required training. The certification shall specify the type of training received and the date received. The certification shall be provided to the COUNTY's Compliance Officer at 3133 N. Millbrook, Fresno, California 93703. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of the terms of this Agreement. 25. ASSURANCES In entering into this Agreement, CONTRA TOR certifies that it nor any of its officers are not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs: that it or any of its officers have not been convicted of a criminal offense related to the provision of health care items or services; nor have they been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering into this Agreement, that CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility for, or involvement with, COUNTY's business operations related to the Federal Health Care Programs and shall remove such CONTRACTOR from any position in which CONTRACTOR's compensation, or the items or services rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR is reinstated into participation in the Federal Health Care Programs. A. If COUNTY has notice that CONTRACTOR has been charged with a criminal offense related to any Federal Health Care Programs, or proposed for exclusion during the term on any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution ofthe charges or the proposed exclusion. B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or -27 -COUN1Y OF FRESNO Fresno, CA subcontractors of CONTRACTOR who, in each case, are expected to perform professional services under this Agreement, will be queried as to whether (1) they are now or ever have been excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they have been convicted of criminal offense related to the provision of health care items or services; and or (3) they have been reinstated to participate in the Federal Health Care Programs.after a period of exclusion, suspension, debarment, or ineligibility. 1. In the event the potential employee or subcontractor informs CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires or engages such potential employee or subcontractor, the CONTRACTOR will ensure that said employee or subcontractor does no work, either directly or indirectly relating to services provided to COUNTY. 2. Notwithstanding the above, COUNTY at its discretion may terminate this Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee of CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY to protect the interests of COUNTY clients. C. CONTRACTOR shall verify (by asking the applicable employees and subcontractors) that all current employees and existing subcontractors who, in each case, are expected to perform professional services under this Agreement: (1) are not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted of a criminal offense related to the provision of health care items or services; and (3) have not been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs a CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs, or has been convicted of a criminal offense relating to the Ill -28 -COUNTY OF FRESNO Fresno, CA provision of heath care services, CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect, relating to services provided to COUNTY. 1. CONTRACTOR agrees to notify COUNTY immediately during the term of this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is providing professional services under Section One (1) of this Agreement is excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating to the provision of health care services. 2. Notwithstanding the above, COUNTY at its discretion may terminate this Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY to protect the interests of COUNTY clients. D. CONTRACTOR agrees to cooperate fully with any reasonable requests for information from COUNTY which may be necessary to complete any internal or external audits relating to CONTRACTOR's compliance with the provisions of this Section. E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of CONTRACTOR's obligations as described in this Section. 26. PROHIBITION ON PUBLICITY None of the funds, materials, property or services provided directly or indirectly under this Agreement shall be used for CONTRACTOR's advertising, fundraising, or publicity (i.e., purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the above, publicity ofthe services described in Section One ~1) ofthis Agreement shall be allowed as necessary to raise public awareness about the availability of such specific services when approved in advance by COUNTY's DBH Director or designee and at a cost to be provided in Section Four (4) of this Agreement for such items as written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related expense(s). -29 -COUNTY OF FRESNO Fresno,CA 27. PROPERTY OF COUNTY A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and intangible property obtained or controlled under COUNTY's Mental Health Plan for use in operational capacity and will benefit COUNTY for a period more than one (1) year. Depreciation of the qualified items will be on a straight-lien basis. for the asset type: For COUNTY purposes, fixed assets must fulfill three qualifications: 1. Asset must have life span of over one year. 2. The asset is not a repair part. 3. The asset must be valued at or greater than the capitalization thresholds Asset type • land • buildings and improvements • infrastructure • be tangible o equipment o vehicles • or intangible asset o Internally generated software o Purchased software o Easements o Patents • and capital lease Threshold $0 $100,000 $100,000 $5,000 $100,000 $5,000 Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed Asset Log, (Exhibit J and Ja-Fixed Asset Log Instructions) will be maintained by COUNTY's Asset Management System and inventoried annually until the asset is fully depreciated. During the terms of this Agreement, CONTRACTOR's fixed assets may be inventoried in comparison to COUNTY's DBH Asset Inventory System. B. Certain purchases under Five Thousand and No/100 Dollars ($5,000.00) but more than One Thousand and No/100 Dollars ($1,000.00) with over one (1) year life span, and are mobile and high risk of theft or loss are sensitive assets. Such sensitive items are not limited to -30 -COUNTY OF FRESNO Fresno, CA computers, copiers, televisions, cameras and other sensitive items as determined by COUNTY's DBH Director or designee. CONTRACTOR maintains a tracking system on the items and are not required to be capitalized or depreciated. The items are subject to annual inventory for compliance. C. Assets shall be retained by COUNTY, as COUNTY property, in the event this Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination of this Agreement, CONTRACTOR shall be physically present when fixed and inventoried assets are returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the assets at the expiration or termination of this Agreement. CONTRACTOR further agrees to the following: 1. To maintain all items of equipment in good working order and condition, normal wear and tear excepted; 2. To label all items of equipment with COUNTY assigned program number, to perform periodic inventories as required by COUNTY and to maintain an inventory list showing where and how the equipment is being used in accordance with procedures developed by COUNTY. All such lists shall be submitted to COUNTY within ten (1 0) days of any request therefore; 3. To report in writing to COUNTY immediately after discovery, the loss or theft of any items of equipment. For stolen items, the local law enforcement agency must be contacted and a copy of the police report submitted to COUNTY D. The purchase of any equipment by CONTRACTOR with funds provided hereunder shall require the prior written approval of COUNTY's DBH Director or designee, shall fulfill the provisions of this Agreement as appropriate, and must be directly related to CONTRACTOR's services or activity under the terms of this Agreement. COUNTY's DBH may refuse reimbursement for any costs resulting from equipment purchased, which are incurred by CONTRACTOR, if prior written approval has not been obtained from COUNTY's DBH Director or designee. E. CONTRACTOR must obtain prior written approval form COUNTY's DBH whenever there is any modification or change in the use of any property acquired or improved, in whole -31 -COUN1Y OF FRESNO Fresno, CA or in part, using funds under this Agreement. If any real or personal property acquired or improved with said funds identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this program, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value of the property, less any portion thereof attributable to expenditures of non- program funds. These requirements shall continue in effect for the life of the property. In the event the program is closed out, the requirements for this Section shall remain in effect for activities or property funded with said funds, unless action is taken by the State government to relieve COUNTY of these obligations. 28. CULTURAL COMPETENCY As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with: A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R. Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance from discriminating against persons based on race, color, national origin, sex, disability or religion. This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and participation in federally funded programs through the provision of comprehensive and quality bilingual services. B. Policies and procedures for ensuring access and appropriate use of trained interpreters and material translation services for all LEP clients, including, but not limited to, assessing the cultural and linguistic needs of its clients, training of staff on the policies and procedures, and monitoring its language assistance program. The CONTRACTOR's procedures must include ensuring compliance of any sub-contracted providers with these requirements. C. CONTRACTOR shall not use minors as interpreters. D. CONTRACTOR shall provide and pay for interpreting and translation services to persons participating in CONTRACTOR's services who have limited or no English language proficiency, including services to persons who are deaf or blind. Interpreter and translation services shall be provided as necessary to allow such participants meaningful access to the programs, services and benefits provided by CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR's "vital documents" (those documents that contain information that is critical for -32 -COUN1Y OF FRESNO Fresno, CA accessing CONTRACTOR's services or are required by law) shall be provided to participants at no cost to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or translate for a program participant, or who directly communicate with a program participant in a language other than English, demonstrate proficiency in the participant's language and can effectively communicate any specialized terms and concepts peculiar to CONTRACTOR's services. E. In compliance with the State mandated Culturally and Linguistically Appropriate Services standards as published by the Office of Minority Health, CONTRACTOR must submit to COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR's plan to address all fifteen national cultural competency standards as set forth in the "National Standards on Culturally and Linguistically Appropriate Services (CLAS)" http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf). COUNTY's annual on-site review of CONTRACTOR shall include collection of documentation to ensure all national standards are implemented. As the national competency standards are updated, CONTRACTOR's plan must be updated accordingly. 29. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104, and 455.106(a)(1),(2). In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2), the following information must be disclosed by CONTRACTOR by completing Exhibit K, "Disclosure of Ownership and Control Interest Statement", attached hereto and by this reference incorporated herein and made part of this Agreement. CONTRACTOR shall submit this form to the Department of Behavioral Health within thirty (30) days ofthe effective date ofthis Agreement. Additionally, CONTRACTOR shall report any changes to this information within thirty five (35) days of occurrence by completing Exhibit K. Submissions shall be scanned PDF copies and are to be sent via email to DBHAdministration@co.fresno.ca.us attention: Contracts Administration. -33 -COUNTY OF FRESNO Fresno, CA 30. DISCLOSURE-CRIMINAL HISTORY AND CIVIL ACTIONS CONTRACTOR is required to disclose if any of the following conditions apply to them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as "CONTRACTOR"): A. Within the three-year period preceding the Agreement award, they have been convicted of, or had a civil judgment rendered against them for: 1. 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; 2. Violation of a federal or state antitrust statute; 3. Embezzlement, theft, forgery, bribery, falsification, or destruction of records; or 4. False statements or receipt of stolen property. B. Within a three-year period preceding their Agreement award, they have had a public transaction (federal, state, or local) terminated for cause or default. Disclosure ofthe above information will not automatically eliminate CONTRACTOR from further business consideration. The information will be considered as part of the determination of whether to continue and/or renew the Agreement and any additional information or explanation that a CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined that the CONTRACTOR failed to disclose required information, any Agreement awarded to such CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms and conditions of the award. CONTRACTOR must sign an appropriate "Certification Regarding Debarment, Suspension, and Other Responsibility Matters-Primary Covered Transactions", Exhibit L, attached hereto and by this reference incorporated herein. Additionally, CONTRACTOR must immediately advise COUNTY in writing if, during the term of this Agreement: (1) CONTRACTOR becomes suspended, debarred, excluded or ineligible for participation in federal or state funded programs or from receiving federal funds as listed in the excluded parties list system (http://www.sam.gov); or (2) -34 -COUNTY OF FRESNO Fresno, CA any of the above listed conditions become applicable to CONTRACTOR. CONTRACTOR shall indemnify, defend and hold COUNTY harmless for any loss or damage resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed "Certification Regarding Debarment, Suspension, and Other Responsibility Matters." 31. AUDITS AND INSPECTIONS The CONTRACTOR shall at any time during business hours, and as often as the COUNTY may deem necessary, make available to COUNTY for examination all of its records and data with respect to the matters covered by this Agreement. CONTRACTOR shall, upon request by COUNTY, permit COUNTY to audit and inspect all such records and data necessary to ensure CONTRACTOR's compliance with the terms of this Agreement. If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00), CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period of three (3) years after final payment under contract (Government Code section 8546.7). 32. COMPLAINTS CONTRACTOR shall log complaints and the disposition of all complaints from a client or a client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries· concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (lOth) day of the following month, in a format that is mutually agreed upon. Besides the detailed complaint log, CONTRACTOR shall provide details and attach documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of their right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to state licensing bodies that affect COUNTY clients within twenty-four (24) hours of receipt of a complaint. Within ten (10) days after each incident or complaint affecting COUNTY-sponsored clients, CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or corrective action taken to resolve the complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit I. CONTRACTOR shall file an incident report for all incidents involving clients, following the Protocol and using the Worksheet identified in Exhibit I. -35 -COUNTY OF FRESNO Fresno, CA 33. DISCLOSURE OF SELF-DEALING TRANSACTIONS This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-profit or non-profit corporation) or if during the term of this agreement, the CONTRACTOR changes its status to operate as a corporation. Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing transactions that they are a party to while CONTRACTOR is providing goods or performing services under this agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR is a party and in which one or more of its directors has a material financial interest. Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a Self-Dealing Transaction Disclosure Form (Exhibit M, attached hereto and by this reference incorporated herein and made part of this Agreement) and submitting it to the COUNTY prior to commencing with the self-dealing transaction or immediately thereafter. 34. NOTICES The persons having authority to give and receive notices under this Agreement and their addresses include the following: COUNTY Director, Fresno County Department of Behavioral Health 3133 N. Millbrook A venue Fresno, CA 93 703 CONTRACTOR Chief Executive Officer Kings View Mental Health 7170 North Financial Drive, Suite 110 Fresno, CA 93 720 Any and all notices between the COUNTY and the CONTRACTOR provided for or permitted under this Agreement or by law shall be in writing and shall be deemed duly served when personally delivered to one of the parties, or in lieu of such personal service, when deposited in the United States Mail, postage prepaid, addressed to such party. 35. GOVERNING LAW The parties agree, that for the purposes of venue, performance under this Agreement is to be in Fresno County, California. The rights and obligations of the parties and all interpretation and performance of this Agreement shall be governed in all respects by the laws of the State of California. -36 -COUNTY OF FRESNO Fresno, CA ) 36. ENTIRE AGREEMENT This Agreement, including all Exhibits between the CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous agreement negotiations, proposals, commitments, writings, advertisements, publications, and understandings of any nature whatsoever unless expressly included in this Agreement. Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill -37 -COUNTY OF FRESNO Fresno, CA 1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and 2 year first hereinabove written. 3 ATTEST: 4 CONTRACTOR 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 KINGS VIEW BEHAVIORAL HEALTH Print Name: A/t-1 fJ 1/k:rret.[) Title: --=et&:...L..-"':..1£L..-=--------- Chairman of Board, or President Or any Vice President By~ PrintName: :Ji,., S. ~tt.J&ue2:= Title: CEo Secretary of Corporation, or Any Assistant Secretary, or Chief Financial Officer, or Any Assistant Treasurer Mailing Address: Kings View Behavioral Health 7170 North Financial Avenue, Suite 110 Fresno, CA 93720 COUNTY OF FRESNO Date: BERNICE E. SEIDEL, Clerk Board of Supervisors Date:~ 14 1 d:DIS PLEASE SEE ADDITIONAL SIGNATURE PAGES ATTACHED -38 -COUNTY OF FRESNO Fresno, CA APPROVED AS TO LEGAL FORM: DANIEL CEDERBORG, COUNTY COUNSEL By Ci~ APPROVED AS TO ACCOUNTING FORM: VICKI CROW, C.P.A., AUDITOR-CONTROLLER/ TREASURER-TAX COLLECTOR By w,( 17~ t ~., REVIEWED AND REC:1ENDED FOR APPROVAL: By ~tlfeel-q Dawan Utecht, Director Department of Behavioral Health Fund/Subclass: 0001/10000 Organization: 56304766 EAST 56304767 WEST Account/Program: 7294/0 WEST FY 2015-16 FY 2016-17 FY 2017-18 TOTAL: EAST $1,300,431 $1,288,124 $1,327,322 $3,915,877 $ 908,422 (9 months) $1,089,550 $1,122,792 $3,120,764 -39 -COUNTY OF FRESNO Fresno,CA MENTAL HEALTH SERVICES ACT PREVENTION AND EARLY INTERVENTION SB 82 RURAL MENTAL HEALTH TRIAGE SERVICES SCOPE OF WORK CONTRACTOR: Kings View Behavioral Health 7170 N. Financial Drive, Suite 110 Fresno, CA 93720 CONTRACT SERVICES: SB 82 Rural Triage Services East and West Fresno County Cities CONTRACT TERM: July 14, 2015 -June 30, 2018 (East) October 1, 2015-June 30, 2018 (West) CONTRACT MEDI-CAL To Be Determined BILLING ADDRESS: CONTRACT MAXIMUM: $7,036,641 (East & West Combined for 3 Terms) Exhibit A Page 1 of8 Fiscal Year Contract Max East Cities Contract Max West Cities PROJECT DESCRIPTION 2015-16 2016-17 2017-18 1,300,431 1,288,124 1,327,322 $3,915,877 908,422 1,089,550 1,122,792 $3,120,764 The County of Fresno, on behalf of the Department of Behavioral Health (DBH), Mental Health Services Act (MHSA), is providing for Rural Mental Health Triage Services (Rural Triage Services) in East and West rural Fresno County cities. Rural Mental Health Triage Services are fully funded by Senate Bill (SB) 82, Public Safety Realignment, Mental Health Services Act Prevention and Early Intervention, and Medi-Cal Federal Financial Participation (FFP). Rural Triage Services will be provided in the East Fresno County cities of: Selma, Sanger, Kingsburg, Fowler, Reedley, Orange Cove and Parlier; and in the rural West Fresno County cities of Firebaugh, Mendota, Kerman, San Joaquin, Huron, and Coalinga. Services should be flexible to the needs of rural Fresno County and may include other rural cities and areas between and around the indicated cities. Rural Triage Services may include, but is not limited to: assessment, Grisis intervention, community referrals and linkages, and short-term/brief case management. In addition, time permitting, services shall also include community outreach, engagement, Exhibit A Page 2 of8 education, and prevention to those potentially in need of services for mental illness and/or co-occurring substance use disorders, the general public, emergency first responders, and other community agencies. Rural Triage Services shall be provided in collaboration with first responders and out in the field where client interaction with law enforcement and emergency services personnel (first responders) typically occurs, and where triage services are most beneficial. PROGRAM GOALS AND OBJECTIVES The goal of this project is to provide triage staff and peer/family consultation service to the East Fresno County Cities' of Selma, Sanger, Parlier, Orange Cove, Fowler, Reedley and Kingsburg, and the West Fresno County Cities' of Firebaugh, Mendota, Kerman, San Joaquin, Huron, and Coalinga in a means that has never been provided. These services shall be provided by interagency coordination between mental health and law enforcement to identify, triage, assess, and connect or reconnect clients to treatment and support, and mitigate unnecessary expenditures of law enforcement. Program Methods: 1) With the placement of triage staff in rural law enforcement agencies, staff will be able to establish data that denotes mental health clients, crisis and interventions for each of the identified communities; a. Data will identify those that have repeated use of 911/crisis resources, triage staff will be available to engage and work with clients/families on a local prevention plan using Wellness Recovery Action Plan tools. 2) Triage staff placement and participation with local law enforcement agencies will increase justice system resources for response to safety and criminal behavior calls/needs. a. Triage staff will be on-site for rapid response and mental health triage and assessment as a subject matter expert and provide appropriate interventions and or linkages with follow up. 3) Individuals with mental illness who engage with law enforcement will have more efficient access to crisis services, receive treatment more sensitive to their mental condition, experience fewer legal concerns and costs related to the encounter with law enforcement, have improved safety and experience less discrimination. 4) Provision of mental health sensitivity and crisis education to assist paramedics to triage clients in an appropriate means if medical criteria do not indicate an Emergency Department admission. To achieve these objectives, refer to Exhibit 8 and Exhibit Be for indicators of what will be tracked. CONTRACTOR RESPONSIBILITIES: CONTRACTOR SHALL: Exhibit A Page 3 of8 1) Establish and maintain co-location space with emergency first responders in rural Fresno County cities. Rural East Fresno County cities served include: Selma, Sanger, Kingsburg, Fowler, Reedley, Orange cove and Parlier; Rural West Fresno County cities served include: Firebaugh, Mendota, Kerman, San Joaquin, Huron, and Coalinga. Not all cities will have co-location facilities available at all times. Co-location arrangements should be flexible and adaptable to meet the evolving needs of the community, in particular the volume of mental health related calls received and services required. 2) Co-respond to potential mental health related calls with emergency first responders and provide rural triage services as indicated herein; 3) In East Fresno County, serve a minimum of 2,1 00 unique individuals in the first 12 months of operation, and 700 unique individuals each 12 month period following. 4) In West Fresno County, serve a minimum of 1,600 unique individuals in the first 12 months of operation, and 500 unique individuals each 12 month period following. 5) Provide culturally, ethnically, and linguistically relevant rural triage services; 6) Meet equipment and technology needs to support the required software. It is anticipated electronic billing will occur though use of a Cisco VPN connection directly into the County's billing module (AVATAR). 7) Ensure billable Mental Health Specialty Services meet any/all County, State, Federal regulations including any utilization review and quality assurance standards. Provide all pertinent and appropriate information in a timely manner to County to bill Medi-Cal for services rendered. The Vendor is responsible for billing private insurance and Medicare, if applicable, prior to billing Medi-Cal. Notice of denial/approval of private insurance and/or Medicare must be received prior to billing Medi-Cal. 8) Refer clients who meet the criteria and are eligible for entitlement programs for benefits/ services. All clients currently in the program and any new clients to be enrolled will go through Social Services to qualify for financial resources. 9) Utilize the County Peer Support and Family Advocate as informational resources to aid in serving the rural communities, including the provision of training, materials creation and ongoing support. 1 O)Ensure Triage staff captures 60% of their time as documentable productive direct services. It is expected that Medi-Cal will be billed when and wherever Exhibit A Page 4 of8 appropriate, however the 60% productivity rate shall also include services such as one-on-one consultations, outreach and education, targeted short-term/brief case management and follow up. When not conducting direct Mental Health Triage services, staff should conduct and document training, outreach, education and engagement in the East 7 cities, West 6 cities, and outlying areas. STAFFING REQUIREMENTS: Staffing shall include: 1. A Supervisory/float Licensed Clinician to provide oversight to all clinicians, work with agencies to build and expand services, and provide crisis response as needed; 2. Staff Clinicians adequate to cover shifts 7 days a week to provide response 18 hours a day; 3. On call/extra help part time clinical staff to cover shifts and back up as needed; 4. One part-time designated administrative support for the purpose of data collection, tracking and reporting; 5. Triage staff skilled at engaging persons in crisis in stabilizing, therapeutic, recovery/wellbeing focused manner; 6. Triage staff with established rotation schedules to meet the needs of the various rural area cities. This should include staff availability for individual/direct calls for services on regularly scheduled days and hours per city. PERFORMANCE MEASURES AND REPORTIING REQUIREMENTS: S8 82 Rural Mental Health Triage Services will be monitored and evaluated based on established performance measures. The attached Exhibit 8, Exhibit 8a, and 8b will be used for evaluating and reporting to the COUNTY, the effectiveness of program strategies and efforts in the provision of S8 82 Rural Triage Services. Exhibit 8 represents the established minimum performance measures which SB 82 Rural Triage Services will be evaluated. Exhibit 8a and Exhibit Bb are used by the CONTRACTOR when requested by COUNTY (typically annually), to report accumulative annual performance outcomes to COUNTY. Proposed and recommended performance measures may be reviewed for input and approval by a designated Department of Behavioral Health work group upon contract execution. The purpose of this input process is to ensure a comprehensive system wide approach to the evaluation of programs through an effective performance reporting process. Evaluation tools (such as Exhibit 8, Ba, and Bb) are subject to modification, replacement, and/or deletion by COUNTY based on the effectiveness of the tools and changes in Federal, State and/or COUNTY reporting requirements. Exhibit A Page 5 of8 In addition to the above mentioned reports, the following is required by the Department of Behavioral Health and must be reported to the Department Analyst each month by the 101h of the month following the report period, unless otherwise indicated. The report period is the prior month of services. As there will be two distinct budgets, one for Eastern and one for Western Fresno County triage services, the following reports must be provided independently for each of the Eastern and Western rural triage services. Funding, billing, staffing, and related data must be collected, maintained and reported separately for Eastern and Western rural triage services. • Monthly Invoicing: Invoices must be submitted by the 1oth of each month to the DBH Analyst and shall include expenses and revenues of the prior month report period. • Staffing Report: Staffing report (Exhibit Be) shall be submitted by the 1 01h of each month to the DBH Program Technician and DBH Analyst and must include each program staffing, their FTE and their salary. Contract Reporting and Evaluation as Required by the SB 82 Triage Services Grant (Exhibit Bd and Exhibit Be) • Process Information Report, due quarterly (one for Eastern and one for Western) and to include the following: i. Number, FTE and type/classification of new triage personnel hired by contractor in each report period, including date of hire and Full-Time-Equivalent (FTE), and total number of triage personnel on staff at the end of each report period. ii. Triage service locations/points of access used in each report period (e.g., hospital emergency rooms, psychiatric hospitals, crisis stabilization programs, homeless shelters, jails, clinics, other community-based service points). iii. Number of clients served at each triage service location/point of access in each report period. • Encounter Based Information Report, due quarterly (one for Eastern and one for Western) and to include the following: i. Total unduplicated persons served in each report period. ii. Total number of service contacts in each report period. iii. Basic demographic information for each individual client served in each report period. Demographic information shall include information on age, race, ethnicity, gender. If available, the Contractor shall also provide information on language spoken, cultural heritage, LGBTQ, and military status. iv. Description of specific services that each client was referred to by triage personnel in each report period. Exhibit A Page 6 of8 v. For each client served in a report period, at the time the triage service was provided, was the person served enrolled in any mental health service? If yes, what service? • Evaluation of Program Effectiveness is due every six (6) months (one for Eastern and one for Western) and to include the following: i. Contractor's goals and objectives for increased triage personnel and/or the improved crisis response system. ii. The system indicators, measures, and outcomes that Contractor used to track to document the effectiveness of services. iii. Evaluation analysis and findings about whether specific system and individual outcomes have been attained. • Success Reporting (Exhibit Bd) is due quarterly (one for Eastern and one for Western) as part of documentation assignments. Included in the report is a fiscal worksheet to identify how an intervention has saved the community/system of care dollars. · STAFF TRAINING AND RESOURCE/COMMUNITY DEVELOPMENT • Time spent completing training and resource/community development shall be captured (not billed as revenue) and reported each month (one for Eastern and one for Western) to the DBH Analyst, by the 1oth of the month following the report period. • Compliance, Billing and Documentation Training are required and will be provided by DBH to Contractor staff annually and with new hires upon hire. FUNDING East and West Rural Triage Services are funded by different revenue streams and shall be budgeted independent of one another. East Rural Triage Services are funded by SB 82 and Medi-Cal FFP revenue generated by the provider; and West Rural Triage Services are funded by Public Safety Realignment, Mental Health Services Act Prevention and Early Intervention, and Medi-Cal FFP revenue generated by the provider. All revenues and expenses shall be managed and reported separately for East and West. Provider shall submit an invoice and associated general ledger each month; one for East and one for West. Refer to Exhibit C "East" and Exhibit C "West" for further breakdown of allocations for each term of the Agreement. The sum of direct costs (staff for data collection, analysis and reporting) and indirect costs (e.g.: support staff, billing) may not exceed fifteen percent (15%) of the total awarded budget. COUNTY RESPONSIBILITIES: COUNTY SHALL: Exhibit A Page 7 of8 1) Provide oversight, support, coordination, and ongoing monitoring of SB 82 Rural Triage Services. 2) Notify CONTRACTOR staff of their responsibilities through DBH letters and other written communications, conferences, formal and informal trainings and individual consultation. 3) Provide individual consultation on a regular basis and facilitate monthly meetings to include DBH assigned Analyst and CONTRACTOR's staff. 4) Provide oversight (through the County Department of Behavioral Health (DBH), Contracts Division of the SB 82 Rural Triage Services program. In addition to contract monitoring, oversight includes, but is not limited to, coordination with the State Department of Mental Health as it may pertain to program administration and outcomes. 5) Assist the CONTRACTOR in making linkages with the total mental health system. This will be accomplished through regularly scheduled meetings as well as formal and informal consultation. 6) Participate in evaluating the performance outcomes and progress of the SB 82 Rural Triage Services program. 7) Receive and analyze statistical performance data information from vendor throughout the term of contract on a monthly basis. DBH will notify the vendor when additional participation is required. The performance measurement process will not be limited to survey instruments but will also include, as appropriate, client and staff interviews, chart reviews, and other methods of obtaining required information. 8) Recognize that cultural competence is a goal toward which professionals, agencies, and systems should strive. Becoming culturally competent is a developmental process and incorporates at all levels the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique needs. Offering those services in a manner that fails to achieve its intended result due to cultural and linguistic barriers is not cost effective. To assist the vendor efforts towards cultural and linguistic competency, DBH shall provide the following at no cost to vendor(s): A. Technical assistance to vendor regarding cultural competency requirements and sexual orientation training; and B. Mandatory cultural competency training including sexual orientation and sensitivity training for DBH and vendor personnel, at minimum once per year. COUNTY will provide mandatory training regarding the special needs of this Exhibit A Page 8 of8 diverse population and will be included in the cultural competence training(s). Sexual orientation and sensitivity to gender differences is a basic cultural competence principle and shall be included in the cultural competency training. Literature suggests that the mental health needs of lesbian, gay, bisexual, transgender (LGBT) individuals may be at increased risk for mental disorders and mental health problems due to exposure to societal stressors such as stigmatization, prejudice and anti-gay violence. Social support may be critical for this population. Access to care may be limited due to concerns about providers' sensitivity to differences in sexual orientation. 9) Assist CONTRACTOR in establishing and maintaining working relationships with rural first responders, including co-location and co-response needs that may arise. Performance Measures Exhibit B SB 82 Rural Mental Health Triage Services Objective Indicators Collection Method Timeline 1 a. Co-location to increase ability to 1 a. Data collection of calls identify those with mental illness via a responded to and frequency of 1 a. From clinician hire and start diagnosis that have law enforcement mental health diagnosis to be date and ongoing. encounters captured on crisis assessment 1 b. Frequency and nature of calls 1 b. Ongoing after clinician hired to be compiled into each 1 b. Ability for triage staff to engage community having a 'top 5 callers' and at least 40 hours spent the officers and clients list and interventions that can be within the designated communicated by any responder community. 1. Establishment of data to better define problem statement and 1 c. Name of person, demographic volume of mental health crisis info, triage outcome, and referrals calls. documented and tracked for linkage success 1 e. Cross walk client information (in a protected means) with law enforcement contacts will identify 'frequent contact clients' and provide a local, sustainable prevention intervention plan 2. Increase time for law 2a. Program Supervisor and/or 2a. Tracked through Avatar (DBH 2a. From clinician hire/start enforcement agencies to respond designated staff will track calls in electronic health record) and date and ongoing. conjunction with law enforcement to community dispatch logs. to safety and criminal behavior identify decrease in mental health 2b. Tracked through Avatar and 2b Monthly reporting and data calls/needs. crisis calls. reports available via that system evaluation 5/20/2015 3a. Triage staff will have referral 3a. Referrals made and Exhibit 8 documented via crisis and 3a. From clinician hire and start 3. Triage staff will be able to resources and relationships built comprehensive assessment or date and ongoing. make appropriate referrals to within each local community. plan of care. local treatment, prevention and 3b. Triage staff will make referrals 3b. Triage staff will be making support services. -upon each (1 00%) contact in the follow up contact for 30 days to 3b. Monthly data sharing. community ensure and assist with all linkages. 4a. Supervisory Paramedics will 4a. Training will be designed receive training and refreshers on 4a. Training outlines and sign in· 4. Quarterly crisis mental health regular basis, pre/post tests will be sheets, analysis of pre/post tests and initiated within 4 months of and sensitivity training for utilized to track training objectives grant award Supervisory Paramedics will 4b. Ql and EMS documentation 4b. Monthly data sharing will decrease use of Emergency 4b. Department review of run Departments. review on a monthly basis to sheets and use of Quality denote use of interventions that determine implementation of Improvement system did not result in emergency information Department access. The program's effectiveness will be evaluated not only by the above indicators, but also through additional means: 1) Shared communication already established with Fresno Police Department and Emergency Medical Services to identify those individuals that are homeless with mental illness that are transient between communities to create a county-wide system of care and intervention plan. 2) Each of the receiving agencies will track 'rural triage' as a referring party to their programs, this will capture referral informat1on for the various prevention and innovation programs that exist outside of traditional mental health facilities in the communities (speakers bureau, cultural based navigation specialists, community gardens, holistic wellness center, etc). 3) Designated staff will check electronic record system at 3, 6 and 9 month intervals to ensure that additional services were not provided outside of the plan of care and referrals as outlined by the clinician. This data will provide an overview of effective and less effective interventions based client needs and each community's resources. Data collection and analysis will be used in community stakeholder processes, client and family forums and other means to solicit enhanced resources as needed based on actual data. 4) Fresno County Department of Behavioral Health will monitor for program effectiveness, via annual reporting to the community, outcomes are vetted through clienUfamily advisory committee and Department outcomes review 5/20/2015 [Type text] PROGRAM TITLE: PROGRAM DESCRIPTION: AGES SERVED: D Children D Adult DATES OF OPERATION: OUTCOME GOAL Performance Measures PROVIDER: D TAY D Older Adult DATES OF DATA REPORTING PERIOD: OUTCOME DATA DEPARTMENT RECOMMENDATION(S): See page 2 for tables Exhibit Ba [Type text] 90 50' M.Tch 2>01-tebnary ::D03 4011(( Ei1 Prior to Enrollment OSince Enrollment Comparisoo of Consuners• Outcomes Prior to and Snce ErTollment i1 AB 2034 Days Hospitalized Days Homele!ll!. Oars lnJail Performance Measures Exhibit Ba [Type text] [Type text] Exhibit Bb Performance Effectiveness Form.-.Attachment C Name of Program: Click here to enter text. What is the Program/Contract Goal? Click here to enter text. Funding Source: D Prevention D Early Intervention D Realignment D Other: Click here to enter text. D Community Services and Supports 0 EPSDT D Innovations Fiscal Information: Budget Amount: $ Click here to enter text. Source(s} of Funding: Click here to enter text. Number of Unique Clients Served During Time Period: Click here to enter text. Number of Services Rendered During Time Period: Click here to enter text. Cost Per Client: Click here to enter text. Type of Program: D Outpatient D Inpatient D Other 0 DBH-Operated D Contract-Operated Level of Care Information: Level of Care: D 1 D 2 D 3 D 4 D 5 Please Describe: Click here to enter text. Target Population Information: Target Population: Click here to enter text. [Type text] [Type text] Exhibit Bb Clinical Information: Do_es the Program Utilize Any of the Following? 0 Evidence Based Practice 0 Evidence Informed Practice 0 Best Practice Please Describe: Click here to enter text. Outcomes and Effectiveness: What Outcome Measures Are Being Used? Click here to enter text. What Outcome Measures/Functional Variables Could Be Added to Better Explain the Program's Effectiveness? Click here to enter text Describe the Program's Effectiveness (i.e. have the program/contract goals been met? Number served, waiting list, wait times, budget to volume, etc): Click here to enter text. What Barriers Prevent the Program from Achieving Better Outcomes? Click here to enter text. What Changes to the Program Would You Recommend to Improve the Effectiveness? Click here to enter text. For Committee Use Only: Recommendations: Click here to enter text. Staffing Report Program: Contract Start Date: Submitted By: Staffing Name/Classification/ Academic Degree (per contract) FTE If not FTE, id % of position for MHSA Program Date Date of Schedule Hire (days, hours) Tentative Hire Date (if offer/start date Identified as Hard to Fill? If yes, note why Bi-Lingual lfyes, note lang spoken Exhibit Be Direct Consumer Service Staff (Mark X, if applies) Other Staff (Mark X, if COPNTY OF FRESNO Success Report Department of Behavioral Health Exhibit Bd Complete the document to report client/family 'successes' with multi-agency/systems involvement REPORT OF SUCCESS MAY BE UTILIZED (DE IDENTIFIED AS NEEDED) IN KUDOS AND NEWLETTERS (NOT A PART OF MEDICAL RECORDS) Name of Person Reporting: Staff Names and Programs Involved in the Success: Client Name: Date of Success Being Reported: Date Range of Success(in days approximately): Account of the success (please include milestones of client, support system and supporting Date of Success Meeting: Attendees to Success Meeting: Signature of Person Reporting Supervisor Signature COUNTY OF FRESNO Success Report Worksheet Department of Behavioral Health Exhibit Bd This worksheet is to be utilized with the Success Report Form. Please complete to the best of your knowledge Number of days homeless Number of days in jail 5150 incidents ER visits Number of FPD contacts Number of EMS contacts Law enforcement contacts (not including FPD contacts) Minutes of Mental Health services provided Number of admissions to crisis unit (CSU) v: ,, " ~' ' ,< ' " -. ' ' _,~:: :.;<'(!: ~~,· ,, ,, ' '" '>"'r.:.,::}, " 'tr: County: Triage Program Name: Program Type(s) Persons Served (Duplicated, Warmline, Outreach, etc.) I rota I Number of Persons Served Community Events (Optional) !Total Number of Events Total Persons Served (Unduplicated) Fresno. Triage Prograi111~3 Mobile Crisis SelectOrie; ; Select.Qne . Seledone State Fiscal Year 2014/15 State Fiscal Year 2015/16 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year I I I I I I I I I I I I Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year I I I I I I I I I I I I Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year 0 Service Contacts (Duplicated) Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year l:r· · · :.1->·•· .. · ·· .~;.·:· -.::·~·:.?:lr.~,·;,~:::~;:.::h·t..<.-:.~;{,<:·:1 Joi:(31.se',Yfc~ col}taqt~ ~{-.. ;;· .:·· Age Group (Unduplicated) Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Children (0-15) Page 1 of 8 Exhibit Be Ethnicity (Unduplicated) Not Hispanic or Latino ·UBkrt9WfiEr\iBF polt~.i:l'':!',;;:, ,, ,, Total Race (Unduplicated) Triage Total Duplicated/Unduplicated Persons Served State Fiscal Year 2014/15 Full Year Page 2 of 8 Exhibit Be State Fiscal Year 2015/16 Full Year Exhibit Be County: Triage Program Name: Language (Unduplicated) Page 3 of 8 LGBQ (Unduplicated) Gay or Lesbian Military Status (Unduplicated) Triage Demographics Reporting {Optional) Unduplicated State Fiscal Year 2014/15 State Fiscal Year 2015/16 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Page 4 of 8 Exhibit Be Optional Exhibit Be County: ·. < · .. Triage Program Name: 'Triage 'Prograft:l :t~f .... State Fiscal Year 2014/15 State Fiscal Year 2015/16 Service Referrals Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year. 1\?1~~1:~J;t-i~~~tll~s~'tvi~~s ; : .... AB109 Programs :.Ml:l/13H Practitione(:., .. Other Page 5 of8 Other Services Adult Protective Services Triage Referrals Reporting Duplicated FY 2014/15 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Page 6 of 8 Exhibit Be FY 2015/16 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year County: Triage Program Name: Enrolled In Mental Health Services (Unduplicated) Total Type of Mental Health Services (Duplicated) Full Service Partnership 'pr~vehtiqn' Program.··.· Other ·Fresno . ·.> Tria&~Pmgl'aml23: '·.· State Fiscal Year 2014/15 Full Year State Fiscal Year 2014/15 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Page 7 of 8 Exhibit Be State Fiscal Year 2015/16 Quarter 1 Quarter 2 Full Year 0 0 0 0 0 State Fiscal Year 2015/16 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year County: Triage Program Name: Mandatory Fields Error Optional Fields Error Fresno ·•·. ·· · .. • .•. Triag¢ ~rograril ~23· State Fiscal Year 2014/15 Page 8 of 8 Exhibit Be State Fiscal Year 2015/16 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Rural Mental Health Triage -East County Kings View Corporation FISCAL YEAR 2015 -2016 Budget Categories - Line Item Description (Must be itemized) FTE% Admin. PERSONNEL SALARIES: 0001 Executive Director (Licensed) 0.02 FTE 0.02 $3,066 0002 Program Director (Licensed) 0.08 FTE 0.08 $7,488 0003 Program Manager (Licensed) .5 FTE 0.50 $4,680 0004 UR Specialist (Licensed) .25 FTE 0.25 0005 Licensed Clinician 7 FTE 7.00 0006 Program Support 0.5 FTE 0.50 $1,976 0007 Medical Director (on-call) 0.01 0008 Per Diem Team responders (Lie) 1,000 hrs/yr n/a SALARY TOTAL 8.36 $17,210 PAYROLL TAXES: 0031 FICA/MEDICARE $1,317 0032 SUI 172 0033 Workers Compensation $688 PAYROLL TAX TOTAL $2,177 EMPLOYEE BENEFITS: 0040 Retirement 0041 Health Insurance (medical, vision, life, dental) $2,926 EMPLOYEE BENEFITS TOTAL SALARY & BENEFITS GRAND TOTAL FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Building 1011 Rent/Lease Equipment 1012 Utilities 1013 Building Maintenance/Janitorial 1015 Rent/Lease Vehicles FACILITY/EQUIPMENT TOTAL OPERATING EXPENSES· 1060 Telephone 1062 Postage 1063 Printing & Reproduction 1066 Office Supplies & Equipment 1069 Program Supplies 1072 Staff Mileage/vehicle maintenance 1074 Staff Training/Registration 1077 Other -Miscellaneous 1078 Other-Staff Recruitment/Background Checks 1079 Communication-Cell phone, Internet OPERATING EXPENSES TOTAL Page 1 of 6 Exhibit C "East" Total Proposed Budget Direct Total $3,066 $7,488 $42,120 $46,800 $20,800 $20,800 $553,280 $553,280 $17,784 $19,760 $6,240 $6,240 $40,000 $40,000 $680,224 $697,434 $52,037 $53,354 $6,802 $6,974 $27,209 $27,897 $86,048 $88,225 $0 $0 $115,638 $118,564 $115,638 $118,564 $904,223 $12,000 $1,800 $3,000 $1,500 $22,000 $40,300 $14,640 $125 $2,500 $7,500 $5,000 $5,000 $10,000 $1,800 $7,550 $14,550 $68,665 Exhibit C "East" FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, General, Property) $8,200 1083 Other-Professional Liability Insurance $3,600 1084 Administrative Overhead (10%) $111 '148 FINANCIAL SERVICES TOTAL $122,948 SPECIAL EXPENSES (Consultant/Etc.)· 1090 Consultant (network & data management) $77,804 1091 Translation Services $2,000 1092 CVSPH Dispatcher services $53,381 SPECIAL EXPENSES TOTAL $133,185 FIXED ASSETS: 2000 Computers & Software $23,610 2001 Furniture & Fixtures $7,500 FIXED ASSETS TOTAL $31 '110 TOTAL PROGRAM EXPENSES $1,300,431 Umts of MEDI-CAL REVENUE: Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) $2.40 $0 3100 Case Management 72,800 $1.86 $135,408 3200 Crisis Services 218,400 $3.58 $781,872 3300 Medication Support $0.00 $0 3400 Collateral $0.00 $0 3500 Plan Development $2.40 $0 3600 Assessment 87,360 $2.40 $209,664 3700 Rehabilitation $0.00 $0 Estimated Medi-Cal Billing Totals 378,560 l;l;i:"~:,;;,{i·;itT£: $1 '126,944 Estimated % of Federal Financial Participation Reimbursement 50.00% $563,472 Estimated % of Clients Served that will be Medi-Cal Eligible 80.00% if .. ~;;~&::;;::,''!0r'tt.;:v:''' MEDI-CAL REVENUE TOTAL $450,778 OTHER REVENUE· 4000 Other -SB 82 Grant $849,653 4100 Other- OTHER REVENUE TOTAL $849,653 MHSA FUNDS· 5100 Prevention and Early Intervention $0 MHSA FUNDS TOTAL $0 TOTAL PROGRAM REVENUE $1,300,431 Page 2 of 6 Rural Mental Health Triage -East County Kings View Corporation FISCAL YEAR 2016 -2017 Budget Categories - Line Item Description (Must be itemized) FTE% Admin. PERSONNEL SALARIES: 0001 Executive Director (Licensed) 0.02 FTE 0.02 $3,158 0002 Program Director (Licensed) 0.08 FTE 0.08 $7,713 0003 Program Manager (Licensed) .5 FTE 0.50 $4,820 0004 UR Specialist (Licensed) .25 FTE 0.25 0005 Licensed Clinician 7 FTE 7.00 0006 Program Support 0.5 FTE 0.50 $2,035 0007 Medical Director (on-call) 0.01 0008 Per Diem Team responders (Lie) 1 ,ooo hrs/yr n/a SALARY TOTAL 8.36 $17,726 PAYROLL TAXES: 0031 FICA/MEDICARE $1,356 0032 SUI 177 0033 Workers Compensation $709 PAYROLL TAX TOTAL $2,242 EMPLOYEE BENEFITS: 0040 Retirement 355 0041 Health Insurance (medical, vision, life, dental) $3,013 EMPLOYEE BENEFITS TOTAL SALARY & BENEFITS GRAND TOTAL FACILITIES/EQUIPMENT EXPENSES: 1010 Rent/Lease Building 1011 Rent/Lease Equipment 1012 Utilities 1013 Building Maintenance/Janitorial 1015 Rent/Lease Vehicles FACILITY/EQUIPMENT TOTAL OPERATING EXPENSES· 1060 Telephone 1062 Postage 1063 Printing & Reproduction 1066 Office Supplies & Equipment 1069 Program Supplies 1072 Staff Mileage/vehicle maintenance 1074 Staff Training/Registration 1077 Other -Miscellaneous 1078 Other -Staff Recruitment/Background Checks 1079 Communication-Cell phone, Internet OPERATING EXPENSES TOTAL Page 3 of 6 Exhibit C "East" Total Proposed Budget Direct Total $3,158 $7,713 $43,384 $48,204 $21,424 $21,424 $569,878 $569,878 $18,318 $20,353 $6,427 $6,427 $41,200 $41,200 $700,631 $718,357 $53,598 $54,954 $7,007 $7,184 $28,025 $28,734 $88,630 $90,872 $14,012 $14,367 $119,108 $122,121 $133,120 $136,488 . $945,717 $12,360 $1,854 $3,090 $1,545 $17,600 $36,449 $15,079 $125 $1,500 $4,000 $5,150 $5,150 $10,000 $800 $2,250 $12,600 $56,654 Exhibit C "East" FINANCIAL SERVICES EXPENSES· 1082 Liability Insurance (Auto, General, Property) $8,446 1083 Other-Professional Liability Insurance $3,708 1084 Administrative Overhead (1 0%) $110,096 FINANCIAL SERVICES TOTAL $122,250 SPECIAL EXPENSES (Consultant/Etc)· .. 1090 Consultant (network & data management) $77,068 1091 Translation Services $2,000 1092 CVSPH Dispatcher services $43,986 SPECIAL EXPENSES TOTAL $123,054 FIXED ASSETS: 2000 Computers & Software $4,000 2001 Furniture & Fixtures FIXED ASSETS TOTAL $4,000 TOTAL PROGRAM EXPENSES $1,288,124 Umts of MEDI-CAL REVENUE: Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) $2.38 $0 3100 Case Management 72,800 $1.84 $133,952 3200 Crisis Services 218,400 $3.54 $773,136 3300 Medication Support $0.00 $0 3400 Collateral $0.00 $0 3500 Plan Development $2.38 $0 3600 Assessment 87,360 $2.38 $207,917 3700 Rehabilitation $0.00 $0 Estimated Medi-Cal Billing Totals 378,560 ~~~,:r~,,y;;;;SJJjlC: i $1,115,005 Estimated % of Federal Financial Participation Reimbursement 50.00% $557,502 '"=w·' Estimated % of Clients Served that will be Medi-Cal Eligible 80.00% ~~~lltf.~»::;t~jl!if:~.j~ MEDI-CAL REVENUE TOTAL $446,002 OTHER REVENUE· 4000 Other-SB 82 Grant $842,122 4100 Other- OTHER REVENUE TOTAL $842,122 MHSA FUNDS· 5100 Prevention and Early Intervention $0 MHSA FUNDS TOTAL $0 TOTAL PROGRAM REVENUE $1,288,124 Page 4 of 6 Rural Mental Health Triage -East County Kings View Corporation FISCAL YEAR 2017 -2018 Budget Categories- Line Item Description (Must be itemized) FTE% Admin. PERSONNEL SALARIES: 0001 Executive Director (Licensed) 0.02 FTE 0.02 $3,253 0002 Program Director (Licensed) 0.08 FTE '0.08 $7,944 0003 Program Manager (Licensed) .5 FTE 0.50 $4,968 0004 UR Specialist (Licensed) .25 FTE 0.25 0005 Licensed Clinician 7 FTE 7.00 0006 Program Support 0.5 FTE 0.50 $2,096 0007 Medical Director (on-call) 0.01 0008 Per Diem Team responders (Lie) 1 ,000 hrs/yr n/a SALARY TOTAL 8.36 $18,261 PAYROLL TAXES: 0031 FICA/MEDICARE $1,397 0032 SUI 183 0033 Workers Compensation $730 PAYROLL TAX TOTAL $2,310 EMPLOYEE BENEFITS: 0040 Retirement $365 0041 Health Insurance (medical, vision, life, dental) $3,104 EMPLOYEE BENEFITS TOTAL $3,470 SALARY & BENEFITS GRAND TOTAL FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Building 1011 Rent/Lease Equipment 1012 Utilities 1013 Building Maintenance/Janitorial 1015 Rent/Lease Vehicles FACILITY/EQUIPMENT TOTAL OPERATING EXPENSES· 1060 Telephone 1062 Postage 1063 Printing & Reproduction 1066 Office Supplies & Equipment 1069 Program Supplies 1072 Staff Mileage/vehicle maintenance 1074 Staff Training/Registration 1077 Other -Miscellaneous 1078 Other -Staff Recruitment/Background Checks 1079 Communication-Cell phone, Internet ', OPERATING EXPENSES TOTAL Page 5 of 6 Exhibit C "East" Total Proposed Budget Direct Total $3,253 $7,944 $44,682 $49,650 $22,067 $22,067 $586,975 $586,975 $18,867 $20,963 $6,620 $6,620 $42,436 $42,436 $721,647 $739,908 $55,206 $56,603 $7,216 $7,399 $28,866 $29,596 $91,288 $93',598 $14,433 $14,798 $122,680 $125,784 $137,113 $140,582 $974,088 $12,731 $1,910 $3,183 $1,591 $17,600 $37,015 $15,532 $125 $1,500 $4,120 $5,305 $5,305 $10,000 $800 $2,250 $12,600 $57,53~ Exhibit C "East" FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, General, Property) $8,699 1083 Other-Professional Liability Insurance $3,819 1084 Administrative Overhead (1 0%) $113,446 FINANCIAL SERVICES TOTAL $125,964 SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant (network & data management) $79,412 1091 Translation Services $2,000 1092 CVSPH Dispatcher services $45,306 SPECIAL EXPENSES TOTAL !' $126,718 FIXED ASSETS: 2000 Computers & Software $6,000 2001 Furniture & Fixtures FIXED ASSETS TOTAL $6,000 TOTAL PROGRAM EXPENSES $1,327,322 Un1ts ot MEDI-CAL REVENUE: Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) $2.46 $0 3100 Case Management 72,800 $1.90 $138,320 3200 Crisis Services 218,400 $3.65 $797,160 3300 Medication Support $0.00 $0 3400 Collateral $0.00 $0 3500 Plan Development $2.46 $0 3600 Assessment 87,360 $2.46 $214,906 3700 Rehabilitation $0.00 $0 Estimated Medi-Cal Billing Totals 378,560 ~\;;;\ $1 '150,386 Estimated % of Federal Financial Participation Reimbursement 50.00% $575,193 Estimated % of Clients Served that will be Medi-Cal Eligible 80.00% 1;;~1!1!\~';\';i.~r~t'>>ifJ!, MEDI-CAL REVENUE TOTAL $460,154 OTHER REVENUE· 4000 Other -SB 82 Grant $867,168 4100 Other- OTHER REVENUE TOTAL $867,168 MHSA FUNDS· 5100 Prevention and Early Intervention $0 MHSA FUNDS TOTAL $0 TOTAL PROGRAM REVENUE $1,327,322 Page 6 of 6 Rural Mental Health Triage -West County Kings View Corporation FISCAL YEAR 2015-2016 (9 Months) Budget Categories- Line Item Description (Must be itemized) i::'TE ~ Admin. PERSONNEL SALARIES: 0001 Executive Director (Licensed) 0.02 FTE 0.02 $2,300 0002 Program Director (Licensed) 0.08 FTE 0.08 $5,616 0003 Program Manager (Licensed) .5 FTE 0.50 $4,680 0004 UR Specialist (Licensed) .25 FTE 0.25 0005 Clinician (1 Licensed, 6 Unlicensed) 7 FTE 7.00 0006 Program Support 0.5 FTE 0.50 $1,976 0007 Medical Director (on-call) 0.01 0008 Per Diem Team responders (Lie) 1 ,000 hrs/yr n/a SALARY TOTAL 8.36 $14,572 PAYROLL TAXES: 0031 FICA/MEDICARE $1 '115 0032 SUI $146 0033 Workers Compensation $583 PAYROLL TAX TOTAL $1,844 EMPLOYEE BENEFITS: 0040 Retirement 0041 Health Insurance (medical, vision, life, dental) $2,477 EMPLOYEE BENEFITS TOTAL SALARY & BENEFITS GRAND TOTAL FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Building 1011 Rent/Lease Equipment 1012 Utilities 1013 Building Maintenance/Janitorial 1015 Rent/Lease Vehicles FACILITY/EQUIPMENT TOTAL OPERATING EXPENSES· 1060 Telephone 1 062 Postage 1 063 Printing & Reproduction 1066 Office Supplies & Equipment 1 069 Program Supplies 1072 Staff Mileage/vehicle maintenance 1 07 4 Staff Training/Registration 1 077 Other -Miscellaneous 1078 Other -Staff Recruitment/Background Checks 1079 Communication-Cell phone, Internet OPERATING EXPENSES TOTAL Page 1 of 6 Exhibit C "West" Total Proposed Budget Direct Total $2,300 $5,616 $42,120 $46,800 $15,600 $15,600 $330,720 $330,720 $17,784 $19,760 $4,680 $4,680 $30,000 $30,000 $440,904 $455,476 $33,729 $34,844 $4,409 $4,555 $17,636 $18,219 $55,774 $57,618 $0 $0 $74,954 $77,431 $74,954 $77,431 $590,525 $12,000 $1,800 $3,000 ' $1,500 $22,000 $40,300 $14,640 $125 $2,500 $7,500 $5,000 $5,000 $10,000 $1,800 $7,550 $14,550 $68,665 Exhibit C "West" FINANCIAL SERVICES EXPENSES· 1082 Liability Insurance (Auto, General, Property) $8,200 1083 Other-Professional Liability Insurance $3,600 1084 Administrative Overhead (1 0%) $77,643 FINANCIAL SERVICES TOTAL $89,443 SPECIAL EXPENSES (Consultant/Etc)· .. 1090 Consultant (network & data management) $54,350 1091 Translation Services $2,000 1092 CVSPH Dispatcher services $32,029 SPECIAL EXPENSES TOTAL $88,379 FIXED ASSETS· 2000 Computers & Software $23,610 2001 Furniture & Fixtures $7,500 FIXED ASSETS TOTAL $31,110 TOTAL PROGRAM EXPENSES $908,422 Units of MEDI-CAL REVENUE: Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) $2.56 $0 3100 Case Management 54,600 $1.98 $108,108 3200 Crisis Services 163,800 $3.81 $624,078 3300 Medication Support $0.00 $0 3400 Collateral $0.00 $0 3500 Plan Development $2.56 $0 3600 Assessment 65,520 $2.56 $167,731 3700 Rehabilitation $0.00 $0 Estimated Medi-Cal Billing Totals 283,920 l:tn~~~::~ $899,917 Estimated % of Federal Financial Participation Reimbursement 50.00% $449,959 Estimated % of Clients Served that will be Medi-Cal Eligible 80.00% ~~1~f,:.~:~;~~fJ~;~i!~~~~~ MEDI-CAL REVENUE TOTAL $359,967 OTHER REVENUE· 4000 Other -Public Safety Realignment Funds $350,000 4100 Other- OTHER REVENUE TOTAL $350,000 MHSA FUNDS· 5100 Prevention and Early Intervention $198,455 MHSA FUNDS TOTAL $198,455 TOTAL PROGRAM REVENUE $908,422 Page 2 of 6 Rural Mental Health Triage -West County Kings View Corporation FISCAL YEAR 2016 -2017 Budget Categories - Line Item Description (Must be itemized) --TE ~ Admin. PERSONNEL SALARIES: 0001 Executive Director (Licensed) 0.02 FTE 0.02 $3,158 0002 Program Director (Licensed) 0.08 FTE 0.08 $7,713 0003 Program Manager (Licensed) .5 FTE 0.50 $4,820 0004 UR Specialist (Licensed) .25 FTE 0.25 0005 Clinician (1 Licensed, 6 Unlicensed) 7 FTE 7.00 0006 Program Support 0.5 FTE 0.50 $2,035 0007 Medical Director (on-call) 0.01 0008 Per Diem Team responders (Lie) 1,000 hrs/yr nla SALARY TOTAL 8.36 $17,726 PAYROLL TAXES: 0031 FICA/MEDICARE $1,356 0032 SUI $177 0033 Workers Compensation $709 PAYROLL TAX TOTAL $2,242 EMPLOYEE BENEFITS: 0040 Retirement 355 0041 Health Insurance (medical, vision, life, dental) $3,013 EMPLOYEE BENEFITS TOTAL SALARY & BENEFITS GRAND TOTAL FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Building 1011 Rent/Lease Equipment 1012 Utilities 1013 Building Maintenance/Janitorial 1015 RenULease Vehicles FACILITY/EQUIPMENT TOTAL OPERATING EXPENSES· 1060 Telephone 1 062 Postage 1 063 Printing & Reproduction 1066 Office Supplies & Equipment 1069· Program Supplies 1072 Staff Mileage/vehicle maintenance 107 4 Staff Training/Registration 1077 Other -Miscellaneous 1078 Other-Staff RecruitmenUBackground Checks 1079 Communication-Cell phone, Internet OPERATING EXPENSES TOTAL Page 3 of 6 Exhibit C "West" Total Proposed Budget Direct Total $3,158 $7,713 $43,384 $48,204 $21,424 $21,424 $440,960 $440,960 $18,318 $20,353 $6,427 $6,427 $41,200 $41,200 $571,713 $589,439 $43,736 $45,092 $5,717 $5,894 $22,869 $23,578 $72,322 $74,564 11434 $11,789 $97,191 $100,204 $108,625 $111;993 $775,996 $12,360 $1,854 $3,090 $1,545 $17,600 $36,449 $15,079 $125 $1,500 $4,000 $5,150 $5,150 $10,000 $800 $2,250 $12,600 $56,654 Exhibit C "West" FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, General, Property) $8,446 1083 Other-Professional Liability Insurance $3,708 1084 Administrative Overhead (10%) $93,124 FINANCIAL SERVICES TOTAL $105,278 SPECIAL EXPENSES (Consultant/Etc.)· 1090 Consultant (network & data management) $65,187 1091 Translation Services $2,000 1092 CVSPH Dispatcher services $43,986 SPECIAL EXPENSES TOTAL $111,173 FIXED ASSETS: 2000 Computers & Software $4,000 2001 Furniture & Fixtures FIXED ASSETS TOTAL $4,000 TOTAL PROGRAM EXPENSES $1,089,550 Units of MEDI-CAL REVENUE: Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) $2.38 $0 31 00 Case Management 72,800 $1.84 $133,952 3200 Crisis Services 218,400 $3.54 $773,136 3300 Medication Support $0.00 $0 3400 Collateral $0.00 $0 3500 Plan Development $2.38 $0 3600 Assessment 87,360 $2.38 $207,917 3700 Rehabilitation $0.00 $0 Estimated Medi-Cal Billing Totals 378,560 I:I)'>"'.;·~?~~Vi~1;;; $1,115,005 Estimated % of Federal Financial Participation Reimbursement 50.00% $557,503 Estimated % of Clients Served that will be Medi-Cal Eligible 80.00% ~~:,~;~r:M~tf~k~~?rJ MEDI-CAL REVENUE TOTAL $446,002 OTHER REVENUE· 4000 Other-Public Safety Realignment (if allocated) or PEl $350,000 4100 Other- OTHER REVENUE TOTAL $350,000 MHSA FUNDS· 5100 Prevention and Early Intervention $293,548 MHSA FUNDS TOTAL $293,548 TOTAL PROGRAM REVENUE $1,089,550 Page 4 of 6 Rural Mental Health Triage -West County Kings View Corporation FISCAL YEAR 2017 -2018 Budget Categories - Line Item Description (Must be itemized) 1-TE "l Admin. PERSONNEL SALARIES: 0001 Executive Director (Licensed) 0.02 FTE 0.02 $3,253 0002 Program Director (Licensed) 0.08 FTE 0.08 $7,944 0003 Program Manager (Licensed) .5 FTE 0.50 $4,968 0004 UR Specialist (Licensed) .25 FTE 0.25 0005 Clinician (1 Licensed, 6 Unlicensed) 7 FTE 7.00 0006 Program Support 0.5 FTE 0.50 $2,096 0007 Medical Director (on-call) 0.01 0008 Per Diem Team responders (Lie) 1, 000 hrs/yr n/a SALARY TOTAL 8.36 $18,261 PAYROLL TAXES: 0031 FICA/MEDICARE $1,397 0032 SUI $183 0033 Workers Compensation $730 PAYROLL TAX TOTAL $2,310 EMPLOYEE BENEFITS: 0040 Retirement $365 0041 Health Insurance (medical, vision, life, dental) $3,104 EMPLOYEE BENEFITS TOTAL $3,469 SALARY & BENEFITS GRAND TOTAL FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Building 1011 Rent/Lease Equipment 1012 Utilities 1013 Building Maintenance/Janitorial 1015 Rent/Lease Vehicles FACILITY/EQUIPMENT TOTAL OPERATING EXPENSES· 1060 Telephone 1 062 Postage 1063 Printing & Reproduction 1066 Office Supplies & Equipment 1069 Program Supplies 1072 Staff Mileage/vehicle maintenance 107 4 Staff Training/Registration 1 077 Other -Miscellaneous 1078 Other-Staff Recruitment/Background Checks 1079 Communication-Cell phone, Internet OPERATING EXPENSES TOTAL Page 5 of 6 Exhibit C "West" Total Proposed Budget Direct Total $3,253 $7,944 $44,682 $49,650 $22,067 $22,067 $454,189 $454,189 $18,867 $20,963 $6,620 $6,620 $42,436 $42,436 $588,861 $607,122 $45,048 $46,445 $5,889 $6,072 $23,554 $24,284 $74,491 $76,801 $11,777 $.12,142 $100,106 $103,210 $111,883 $115,352 $799,275 $12,731 $1,910 $3,183 $1,591 $17,600 $37,015 $15,532 $125 $1,500 $4,120 $5,305 $5,305 $10,000 $800 $2,250 $12,600 $57,537 Exhibit C "West" FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, General, Property) $8,699 1083 Other-Professional Liability Insurance $3,819 1084 Administrative Overhead (10%) $95,965 FINANCIAL SERVICES TOTAL $108,483 SPECIAL EXPENSES (Consultant/Etc.)· 1090 Consultant (network & data management) $67,176 1091 Translation Services $2,000 1092 CVSPH Dispatcher services $45,306 SPECIAL EXPENSES TOTAL $114,482 FIXED ASSETS· 2000 Computers & Software $6,000 2001 Furniture & Fixtures FIXED ASSETS TOTAL $6,000 TOTAL PROGRAM EXPENSES $1,122,792 Units of MEDI-CAL REVENUE: Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) $2.46 $0 31 00 Case Management 72,800 $1.90 $138,320 3200 Crisis Services 218,400 $3.65 $797,160 3300 Medication Support $0.00 $0 3400 Collateral $0.00 $0 3500 Plan Development $2.46 $0 3600 Assessment 87,360 $2.46 $214,906 3700 Rehabilitation $0.00 $0 Estimated Medi-Cal Billing Totals 378,560 l1*t~i:· ;;~'~'ttf];:t*i ;· •• $1,150,386 Estimated % of Federal Financial Participation Reimbursement 50.00% $575.193 Estimated % of Clients Served that will be Medi-Cal Eligible 80.00% ~~~:1i~~j~{{li%~{£1;1f~; y MEDI-CAL REVENUE TOTAL $460,154 OTHER REVENUE· 4000 Other -Public Safety Realignment (if allocated) or PEl $350,000 4100 Other- OTHER REVENUE TOTAL $350,000 MHSA FUNDS· 5100 Prevention and Early Intervention $312,638 MHSA FUNDS TOTAL $312,638 TOTAL PROGRAM REVENUE $1,122,792 Page 6 of 6 ExhibitD Page 1 of3 FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM CONTRACTOR CODE OF CONDUCT AND ETHICS Fresno County is firmly committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to the provision and payment of mental health services. Mental health contractors and the manner in which they conduct themselves are a vital part of this commitment. Fresno County has established this Contractor Code of Conduct and Ethics with which contractor and its employees and subcontractors shall comply. Contractor shall require its employees and subcontractors to attend a compliance training that will be provided by Fresno County. After completion of this training, each contractor, contractor's employee and subcontractor must sign the Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or designee. Contractor and its employees and subcontractor shall: 1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing for mental health services. 2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their professional dealing related to their contract with the County and avoid any conduct that could reasonably be expected to reflect adversely upon the integrity of the County. 3. Treat County employees, consumers, and other mental health contractors fairly and with respect. 4. NOT engage in any activity in violation ofthe County's Compliance Program, nor engage in any other conduct which violates any applicable law, regulation, rule or guideline 5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are consistent with all applicable laws, regulations, rules or guidelines. 6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement of any kind are submitted. 7. Bill only for eligible services actually rendered and fully documented. Use billing codes that accurately describe the services provided. Exhibit D Page 2 of3 8. Act promptly to investigate and correct problems if errors in claims or billing are discovered. 9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct and Ethics by County employees or other mental health contractors, or report any activity that they believe may violate the standards of the Compliance Program, or any other applicable law, regulation, rule or guideline. Fresno County prohibits retaliation against any person making a report. Any person engaging in any form of retaliation will be subject to disciplinary or other appropriate action by the County. Contractor may report anonymously. 10. Consult with the Compliance Officer ifyou have any questions or are uncertain of any Compliance Program standard or any other applicable law, regulation, rule or guideline. 11. Immediately notify the Compliance Officer if they become or may become an Ineligible person and therefore excluded from participation in the Federal Health Care Programs. Fresno Countv Mental Health Compliance Program Contractor Acknowledgment and Agreement Exhibit D Page 3 of3 I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental Health Compliance Program and understand the contents thereof. I further agree to abide by the Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my responsibilities as a mental health contractor for Fresno County. I understand and accept my responsibilities under this Agreement. I further understand that any violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program may result in termination of my agreement with Fresno County. I further understand that Fresno County will report me to the appropriate Federal or State agency. For Individual Providers Name (print): _______________ _ Discipline: D Psychiatrist D Psychologist D LCSW D LMFT Signature: ___________________________ _ Date: I I For Group or Organizational Providers Group/Org. Name (print): _4A-'J;-'-,_1U--b~~...r __ f/j_,_~_uJ ______ _ Employee Name (print): __ ---1!_~~e~CJ::..._'-__ ___:_:t/o __ ov ___ -Q-.:__ __________ _ Discipline: D Psychiatrist D Psychologist D LCSW D LMFT Jf1S(}.) f}f~_..;;_ ~ ~~ ~ r::{c;ther: Job Title (if different from Discipline): ~C~~=----------­ Signature: ---~~~----~-:-./~fi-L~'----------Date: 0 /~£ I.J--4 I$---. Documentation Standards For Client Records Exhibit E Page 1 of3 The documentation standards are described below under key topics related to client care. All standards must be addressed in the client record; however, there is no requirement that the record have a specific document or section addressing these topics. A. Assessments 1. The following areas will be included as appropriate as a part of a comprehensive client record. • Relevant physical health conditions reported by the client will be prominently identified and updated as appropriate. • Presenting problems and relevant conditions affecting the client's physical health and mental health status will be documented, for example: living situation, daily activities, and social support. • Documentation will describe client's strengths in achieving client plan goals. • Special status situations that present a risk to clients or others will be prominently documented and updated as appropriate. • Documentations will include medications that have been described by mental health plan physicians, dosage of each medication, dates of initial prescriptions and refills, and documentations of informed consent for medications. • Client self report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities will be clearly documented. • A mental health history will be documented, including: previous treatment dates, providers, therapeutic interventions and responses, sources of clinical data, relevant family information and relevant results of relevant lab tests and consultations reports. • For children and adolescents, pre-natal and perinatal events and complete developmental history will be documented. • Documentations will include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over-the-counter drugs. • A relevant mental status examination will be documented. • A five axis diagnosis from the most current DSM, or a diagnosis from the most current ICD, will be documented, consistent with the presenting problems, history mental status evaluation and/or other assessment data. 2. Timeliness/Frequency Standard for Assessment • An assessment will be completed at intake and updated as needed to document changes in the client's condition. • Client conditions will be assessed at least annually and, in most cases, at more frequent intervals. B. Client Plans l. Client plans will: 0302 fdbh • have specific observable and/or specific quantifiable goals • identify the proposed type( s) of intervention • have a proposed duration of intervention( s) • be signed (or electronic equivalent) by: *the person providing the service(s), or * a person representing a team or program providing services, or * a person representing the MHP providing services Exhibit E Page 2 of3 * when the client plan is used to establish that the services are provided under the direction of an approved category of staff, and if the below staff are not the approved category, * a physician * a licensed/ "waivered" psychologist * a licensed/ "associate" social worker * a licensed/ registered/marriage and family therapist or * a registered nurse • In addition, * client plans will be consistent with the diagnosis, and the focus of intervention will be consistent with the client plan goals, and there will be documentation of the client's participation in and agreement with the plan. Examples of the documentation include, but are not limited to, reference to the client's participation and agreement in the body qfthe plan, client signature on the plan, or a description of the client's participation and agreement in progress notes. I *client signature on the plan will be used as the means by which the CONTRACTOR(S) documents the participation of the client j * when the client's signature is required on the client plan and the client refuses or is unavailable for signature, the client plan will include a written explanation offhe refusal or unavailability. • The CONTRACTOR(S) will give a copy of the client plan to ~he client on request. 2. Timeliness/Frequency of Client Plan: • Will be updated at least annually • The CONTRACTOR(S) will establish standards for timeliness and frequency for the individual elements of the client plan described in item 1. C. Progress Notes 1. Items that must be contained in the client record related to the client's progress in treatment include: • The client record will provide timely documentation of relevant aspects of client care • Mental health staff/practitioners will use client records to document client encounters, including relevant clinical decisions and interventions • All entries in the client record will include the signature of the person providing the service (or electronic equivalent); the person's professional degree, licensure or job title; and the relevant identification number, if applicable • All entries will include the date services were provided • The record will be legible • The client record will document follow-up care, or as appropriate, a discharge summary 0302 fdbh 2. Timeliness/Frequency of Progress Notes: Exhibit E Page 3 of3 Progress notes shall be documented at the frequency by type of service indicated below: A. Every Service Contact • Mental Health Services • Medication Support Services • Crisis Intervention 0302 fdbh Exhibit F State Exhibit 6 -Quarterly Report Page 1 of 3 Current Quarterly Progress Report Process Overview Current Regulations Title 9, Division 1, Chapter 14. Article 5: Quarterly Progress Reports must be submitted to the State Department of Mental Health no later than 60 days following the end of each reporting quarter and are compiled by service category for each approved program and/or service. The following information must be included in the Quarterly Progress Report: • The targeted number of individuals or families to be served in each reporting quarter by each program/service during the quarter • The total number of individuals or families actually served in each reporting quarter by each program/service during the quarter • The final Quarterly Progress Report must include the total number of unduplicated individuals or families served by each program/service during the fiscal year Following is a review of how to calculate individuals served within each service category (Full Service Partnerships, System Development and Outreach and Engagement). Quarterly Counts: The quarterly count is unduplicative within quarters but is duplicative between quarters. The number of actual individuals served equals: the total number of individuals or families enrolled in the program on the first day of each quarter plus any individuals or families newly enrolled throughout the quarter. Example: Explanation: Q1: At the beginning of Quarter 1, 1 0 people were enrolled and 10 people were newly enrolled throughout the quarter, so the total actual served for Quarter 1 would equal 20 (10 + 10 = 20). Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more people were newly enrolled, so the total actual served would equal 25 (20 + 5 = 25). Exhibit F State Exhibit 6 -Quarterly Report Page 2 of 3 Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more people were newly enrolled throughout the quarter, so the total actual served would equal 27 (20 + 7 = 27). (Five people disenrolled the previous quarter, so on the first day of Quarter 3, 20 people were currently enrolled.) Q4: At the beginning of Quarter 4, 26 people were currently enrolled because one had disenrolled during Quarter 3, but 5 had been newly enrolled so the total actual served of 31 (26 + 5 = 27) Quarterly targets: The quarterly target is an estimate of the total number of individuals you expect to serve for that quarter. Targeted counts should follow the same strategy as for actual counts described above. Unduplicated Annual Counts: The unduplicated annual count: Equals the total number of people served for the entire year. Example: Q1: At the beginning of Quarter 1, 10 people were enrolled and 1 0 people were newly enrolled throughout the quarter, so the total unduplicated for Quarter 1 would equal 20 (1 0 + 10 = 20). Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more people were newly enrolled, so the total unduplicated for quarter 2 would be 5. Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more people were newly enrolled throughout the quarter, so the total unduplicated for quarter 3 would be 7. Q4: At the beginning of Quarter 4, 26 people were currently enrolled and 5 had been newly enrolled so the total unduplicated for quarter 4 would be 5. Total Unduplicated Annual Actual Served: 20 + 5 + 7 + 5 = 37 Total Unduplicated Annual Targets: The unduplicated annual target is an estimate of the total number of unduplicated individuals you expect to serve annually, Exhibit F State Exhibit 6 -Quarterly Report Page 3 of 3 Options for Improving the MHSA Quarterly Progress Reporting Process Outreach and Engagement: There are many different methods of providing outreach and engagement services. Some services are offered in a group or community wide forum and sometimes services are offered individually. Ideally, it would be helpful to have a combination of service based and individual level data collection that is submitted on a quarterly basis. Potential Methods for reporting counts in these service categories: Categories could be created based on the nature of the services provided. There are two very broad categories of services and they could be reported differently based on these categories: For instance: Community Forum Outreach and Engagement Activities: When conducting a community forum activity such as a county-wide presentation to a group of people about a mental health issue, a count of the number of presentations and the number of individuals that attended could be submitted. Some indication of the purpose of each event would also be helpful. For instance, broad categories such as education, workforce development, stigma reduction or outreach to engage in services could be indicated. Individual Outreach and Engagement Services: When conducting outreach and engagement services to individuals, you may have multiple contacts with an individual prior to engaging them into services. Counting the number of contacts rather than the number of individuals would provide more accurate information regarding individual services. In addition, some demographic information regarding the individuals receiving services within these categories would be helpful including gender, age and race/ethnicity. In addition, information regarding the number of face-to-face contacts vs. phone contacts would also be useful. System Development: There are many types of services provided through this category. Some services maybe offered in a group or community wide forum and some services may be offered to individuals and families. In addition, some services center around linkage with other community based organizations. Should the services be categorized similar to what has been proposed for Outreach and Engagement or should there be different categories for System Development services? Exhibit Fa :y~~~,§R~~tf!~QG$1i~.siq~~~§ ~t1l . Estimated/Actual Population Served Exhibit G STATE MENTAL HEALTH REQUIREMENTS 1. CONTROL REQUIREMENTS The COUNTY and its subcontractors shall provide services in accordance with all applicable Federal and State statutes and regulations. 2. PROFESSIONAL LICENSURE All (professional level) persons employed by the COUNTY Mental Health Program (directly or through contract) providing Short-Doyle/Medi-Cal services have met applicable professional licensure requirements pursuant to Business and Professions and Welfare and Institutions Codes. 3. CONFIDENTIALITY CONTRACTOR shall conform to and COUNTY shall monitor compliance with all State of California and Federal statutes and regulations regarding confidentiality, including but not limited to confidentiality of information requirements at 42, Code of Federal Regulations sections 2.1 et seq; California Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code ofRegulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 ofthe California Civil Code. 4. NON-DISCRIMINATION A. Eligibility for Services CONTRACTOR shall prepare and make available to COUNTY and to the public all eligibility requirements to participate in the program plan set forth in the Agreement. No person shall, because of ethnic group identification, age, sex, color, disability, medical condition, national origin, race, ancestry, marital status, religion, religious creed, political belief or sexual preference be excluded from participation, be denied benefits of, or be subject to discrimination under any program or activity receiving Federal or State of California assistance. B. Employment Opportunity CONTRACTOR shall comply with COUNTY policy, and the Equal Employment Opportunity Commission guidelines, which forbids discrimination against any person on the grounds of race, color, national origin, sex, religion, age, disability status, or sexual preference in employment practices. Such practices include retirement, recruitment advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates of pay' or other forms of compensation, use of facilities, and other terms and conditions of employment. C. Suspension of Compensation If an allegation of discrimination occurs, COUNTY may withhold all further funds, until CONTRACTOR can show clear and convincing evidence to the satisfaction of Exhibit G COUNTY that funds provided under this Agreement were not used in connection with the alleged discrimination. D. Nepotism Except by consent of COUNTY's Department of Behavioral Health Director, or designee, no person shall be employed by CONTRACTOR who is related by blood or marriage to, or who is a member of the Board of Directors or an officer of CONTRACTOR. 5. PATIENTS' RIGHTS CONTRACTOR shall comply with applicable laws and regulations, including but not limited to, laws, regulations, and State policies relating to patients' rights. Medi-Cal Organizational Provider Standards EXHffiiTH Page 1 of2 1. The organizational provider possesses the necessary license to operate, if applicable, and any required certification. 2. The space owned, leased or operated by the provider and used for services or staff meets local fire codes. 3. The physical plant of any site owned, leased, or operated by the provider and used for services or staff is clean, sanitary and in good repair. 4. The organizational provider establishes and implements maintenance policies for any site owned, leased, or operated by the provider and used for services or staff to ensure the safety and well being of beneficiaries and staff. 5. The organizational provider has a current administrative manual which includes: personnel policies and procedures, general operating procedures, service delivery policies, and procedures for reporting unusual occurrences relating to health and safety issues. 6. The organizational provider maintains client records in a manner that meets applicable state and federal standards. 7. The organization provider has staffing adequate to allow the County to claim federal financial participation for the services the Provider delivers to beneficiaries, as described in Division 1, Chapter 11, Subchapter 4 ofTitle 9, CCR, when applicable. 8. The organizational provider has written procedures for referring individuals to a psychiatrist when necessary, or to a physician, if a psychiatrist is not available. 9. The organizational provider has as head of service a licensed mental health professional of other appropriate individual as described in Title 9, CCR, Sections 622 through 630. 10. For organizational providers that provide or store medications, the provider stores and dispenses medications in compliance with all pertinent state and federal standards. In particular: A. All drugs obtained by prescription are labeled in compliance with federal and state laws. Prescription labels are altered only by persons legally authorized to do so. B. Drugs intended for external use only or food stuffs are stored separately from drugs for internal use. C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F and refrigerated drugs at 36-46 degrees F. EXHffiiTH Page 2 of2 D. Drugs are stored in a locked area with access limited to those medical personnel authorized to prescribe, dispense or administer medication. E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and initialed when opened. F. A drug log is maintained to ensure the provider disposes of expired, contaminated, deteriorated and abandoned drugs in a manner consistent with state and federal laws. G. Policies and procedures are in place for dispensing, administering and storing medications. 11. For organizational providers that provide day treatment intensive or day rehabilitation, the provider must have a written description of the day treatment intensive and/or day treatment rehabilitation program that complies with State Department of Mental Health's day treatment requirements. The COUNTY shall review the provider's written program description for compliance with the State Department of Mental Health's day treatment requirements. 12. The COUNTY may accept the host county's site certification and reserves the right to conduct an on-site certification review at least every three years. The COUNTY may also conduct additional certification reviews when: • The provider makes major staffing changes. • The provider makes organizational and/or corporate structure changes (example: conversion from a non-profit status). • The provider adds day treatment or medication support services when medications shall be administered or dispensed from the provider site. • There are significant changes in the physical plant of the provider site (some physical plant changes could require a new fire clearance). • There is change of ownership or location. • There are complaints against the provider. • There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or members ofthe community. Proposal No. Exhibit I Page 1 of 4 FRESNO COUNTY MENTAL HEALTH PLAN GRIEVANCES AND INCIDENT REPORTING Grievances Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance and appeal process and an expedited appeal process to resolve grievances and disputes at the earliest and the lowest possible level. Title 9 of the California Code of Regulations requires that the MHP and its fee-for-service providers give verbal and written information to Medi-Cal beneficiaries regarding the following: • How to access specialty mental health services • How to file a grievance about services • How to file for a State Fair Hearing The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance form, an appeal form, and Request for Change of Provider Form. All of these beneficiary materials must be posted in prominent locations where Medi-Cal beneficiaries receive outpatient specialty mental health services, including the waiting rooms of providers' offices of service. Please note that all fee-for-service providers and contract agencies are required to give their clients copies of all current beneficiary information annually at the time their treatment plans are updated and at intake. Beneficiaries have the right to use the grievance and/or appeal process without any penalty, change in mental health services, or any form of retaliation. All Medi-Cal beneficiaries can file an appeal or state hearing. Grievances and appeals forms and self addressed envelopes must be available for beneficiaries to pick up at all provider sites without having to make a verbal or written request. Forms can be sent to the following address: Fresno County Mental Health Plan P.O. Box 712 Fresno, CA 93712 (800) 654-3937 (for more information) (559) 488-3055 (TTY) Provider Problem Resolution and Appeals Process The MHP uses a simple, informal procedure in identifying and resolving provider concerns and problems regarding payment authorization issues, other complaints and concerns. Informal provider problem resolution process-the provider may first speak to a Provider Relations Specialist (PRS) regarding his or her complaint or concern. The PRS will attempt to settle the complaint or concern with the provider. If the attempt is unsuccessful and the provider chooses to forego the informal grievance process, the provider will be advised to file a written complaint to the MHP address (listed above). Formal provider appeal process-the provider has the right to access the provider appeal process at any time before, during, or after the provider problem resolution process has Proposal No. Exhibit I Page 2 of4 begun, when the complaint concerns a denied or modified request for MHP payment authorization, or the process or payment of a provider's claim to the MHP. Pavment authorization issues-the provider may appeal a denied or modified request for payment authorization or a dispute with the MHP regarding the processing or payment of a provider's claim to the MHP. The written appeal must be submitted to the MHP within 90 calendar days of the date of the receipt of the non-approval of payment. The MHP shall have 60 calendar days from its receipt of the appeal to inform the provider in writing of the decision, including a statement of the reasons for the decision that addresses each issue raised by the provider, and any action required by the provider to implement the decision. If the appeal concerns a denial or modification of payment authorization request, the MHP utilizes a Managed Care staff who was not involved in the initial denial or modification decision to determine the appeal decision. If the Managed Care staff reverses the appealed decision, the provider will be asked to submit a revised request for payment' within 30 calendar days of receipt of the decision Other complaints-if there are other issues or complaints, which are not related to payment authorization issues, providers are encouraged to send a letter of complaint to the MHP. The provider will receive a written response from the MHP within 60 calendar days of receipt of the complaint. The decision rendered buy the MHP is final. Proposal No. Exhibit I Page 3 of4 PROTOCOL FOR COMPLETION OF INCIDENT REPORT • The Incident Report must be completed for all incidents involving clients. The staff person who becomes aware of the incident completes this form, and the supervisor co-signs it. • When more than one client is involved in an incident, a separate form must be completed for each client. Where the forms should be sent -within 24 hours from the time of the incident • Incident Report should be sent to: • DBH Program Supervisor Proposal No. 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 4 of4 3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed ~,Nrite comments on an 8 1/2 sheet of paper and attach to worksheet. Outcome severity: Nonexistent IDI inconsequential 0 consequential IDI death IDI not applicable 101 unknown 0 4. Response: a) corrective action, b) Plan of Action, c) other Completed by (print name) -------------------------- Completed by (signature) _____________ Date completed Reviewed by Supervisor (print name) Supervisor Signature Date 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Vendor: Contract# Exhibit J Contact Person Contact# 20~--------~--------~--------~----------~--~~--~------~----~-------b------~------~------~----~ Header Header Header Header Header Header a c d e f g h j k l m FIXED ASSET AND SENSITIVE ITEM TRACKING Vendor Program Contract # Contact Person Contact # Date Prepared Item Model Serial # Fixed Asset Indicate the legal provide services. Indicate the title of the project as described in the contract with the County. Indicate the assigned County contract number. If not known, County staff can provide. Indicate the first and last name of the primary agency contact for the contract. Indicate the most appropriate telephone number of the primary agency contact for the contract. Indicate the most current date that the tracking form was completed by the vendor. Identify the item by providing a commonly recognized description of the item. Identify the model number for the item, if applicable. Identify the serial number for the item, if applicable. Mark the box with an "X" if the cost of the item is $5,000 or more to indicate that the item is a fixed asset. Mark the box with an "X" if the item meets the criteria Sensitive Item of a sensitive item as defined by the County. Indicate the date that the agency submitted a request Date Requested to the County to purchase the item. Date Approved Location Condition Fresno County Inventory Number Cost Indicate the date that the County approved the request to purchase the item. Indicate the physical· location of the item Indicate the general condition of the item (New, Good, Worn, Bad). Indicate the FR # provided by the County for the item. Indicate the total purchase price of the item including sales tax and other costs, such as shipping. Exhibit Ja Required Required Required Required Required Required Required Conditional Conditional Conditional Conditional Required Required Required Required Conditional Required I. ldenti Name of entity Address (number, street) DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT D/B/A ZIP code Exhibit K Page 1 of2 717CJ /lJ · F:·IU/J111Ct';4/ 927La CLIAnumber Telephone number ( .s'set ) J_S{, -7 {, ,, II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and addresses of individuals or corporations under "Remarks" on page 2. Identify each item number to be continued. A. Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons or organizations in any of the programs established by Titles XVIII, XIX, or XX? ........................................................................................................................ . B. Are there any directors, officers, agents, or managing employees of the institution, agency, or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX? ..................................................................................... . C. Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) .......... . YES NO 0 0 / 0 / Ill. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under "Remarks." NAME ,lr I Al; ADDRESS EIN /Utn-Jl--v~lr i\lf" B. Type of entity: o Sole proprietorship o Partnership o Corporation o Unincorporated Associations o Other (specify) ________ _ C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations under "Remarks." D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses of individuals, and provider numbers .......................................................................................................... . 0 0 NAME ADDRESS PROVIDER NUMBER IV. A. Has there been a change in ownership or control within the last year? ...................................................... . If yes, give date. ------------------- B. Do you anticipate any change of ownership or control within the year? ...................................................... . lfyes,when? ___________________ _ C. Do you anticipate filing for bankruptcy within the year? ............................................................................... . lfyes,when? ___________________ _ V. Is the facility operated by a management company or leased in whole or part by another organization? ......... . If yes, give date of change in operations. ------------ VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year? ........ . VII. A. Is this facility chain affiliated? ..................................................................................................................... . If es, list name, address of cor oration, and EIN. Name EIN Address (number. name) City State B. If the answer to question VII .A. is NO, was the facility ever affiliated with a chain? (If yes, list name, address of corporation, and EIN.) Name EIN Address (number, name) City State ZIP code ZIP code Exhibit K Page 2 of2 YES NO 0 r/ 0 ' 0 rl 0 / 0 / 0 rf 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 Jaws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the agency, as appropriate. Name of authorized representative (typed) Title Leo~ c.co Signature Date Remarks Exhibit L CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. M:\MHSA\CONTRACTS AND PROGRAMSISB 82 RURAL TRIAGEIHISTORICAL RECORDS\CONTRACTIEXHIBIT L-CERTIFICATION REGARDING DEBARMENT .DOC Exhibit L CERTIFICATION (1) The prospective primary participant certifies to the best of its knowledge and belief, that it, its owners, officers, corporate managers and partners: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; · (c) 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: ~CFo Date: (Printed Name & Title) C:\USERS\CDEEGANIAPPDATAILOCAL\MICROSOFnWINDOWSITEMPORARY INTERNET FILES\CONTENT.OUTLOOKIOEQQGMSTIEXHIBIT L- CERTIFICATION REGARDING DEBARMENT.DOC SELF-DEAUNG TRANSACfiON DISCLOSURE FORM ExhibitM Page 1 of2 In order to conduct business with the County of Fresno (hereinafter referred to as "County"), members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must disclose any self-dealing transactions that they are a party to while providing goods, performing services, or both for the County. A self-dealing transaction is defined below: "A self-dealing transaction means a transaction to which the corporation is a party and in which one or more of its directors has a material financial interest" The definition above will be utilized for purposes of completing this disclosure form. INSTRUCTIONS (1) Enter board member's name, job title (if applicable), and date this disclosure is being made. (2) Enter the board member's company/agency name and address. (3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the County. At a minimum, include a description of the following: a. The name of the agency/company with which the corporation has the transaction; ,and b. The nature of the material financial interest in the Corporation's transaction that the board member has. (4) Describe in detail why the self-dealing transaction is appropriate based on applicable provisions of the Corporations Code. (5) Form must be signed by the board member that is involved in the self-dealing transaction described in Sections (3) and (4). ExhibitM Page 2 of2