HomeMy WebLinkAbout32241
COUNTY OF FRESNO
Fresno, CA
- 1 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
AGREEMENT
THIS AGREEMENT is made and entered into this ___________day of _____________, 2015,
by and between the COUNTY OF FRESNO, a political subdivision of the State of California,
hereinafter referred to as “COUNTY”, and CALIFORNIA PSYCHOLOGICAL INSTITUTE, a
private Corporation, whose address is 1470 W. Herndon Avenue, Suite 300, Fresno, California 93711,
hereinafter referred to as “CONTRACTOR”.
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Social Services (DSS), is in need of a
qualified agency to provide outpatient specialty mental health, court-specific, and community support
services for children and youths involved in the Child Welfare Services (CWS) system; and
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is a Mental Health
Plan (MHP) as defined in Title 9 of the California Code of Regulations (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 shall perform all services and fulfill all responsibilities as set
forth in the Summary of Services, attached hereto as Exhibit A and incorporated herein by reference.
B. CONTRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 952-5250 dated February 25, 2014,
Addendum No. One (1) to COUNTY’s RFP No. 952-5250 dated March 10, 2014, and that
CONTRACTOR’s Response to said Revised RFP dated April 4, 2014; all incorporated herein by
reference and made part of this Agreement. In the event of any inconsistency among these documents,
the inconsistency shall be resolved by giving precedence in the following order of priority: (1) to this
Agreement, including all Exhibits; (2) to the RFP; (3) Addendum No. One (1) to COUNTY’s RFP No.
952-5250 dated March 10, 2014; and (4) CONTRACTOR’s Response to said Revised RFP dated April
4, 2014. A copy of COUNTY’s RFP No. 952-5250 and CONTRACTOR’s response thereto shall be
COUNTY OF FRESNO
Fresno, CA
- 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
retained and made available during the term of this Agreement by COUNTY’s DSS Administrative
unit.
C. It is acknowledged by all parties hereto that COUNTY’s DSS and DBH
Administrative Units shall monitor the services provided by CONTRACTOR, as specified herein.
D. CONTRACTOR shall participate in periodic workgroup meetings including staff
from COUNTY’s DSS and DBH Administrative units. The meetings shall be held monthly, or as
needed, to discuss program requirements, data reporting, outcomes measurement, training, policies and
procedures, and overall program operations.
E. It is acknowledged by all parties hereto that upon execution of this Agreement,
CONTRACTOR’s service site shall be 1470 W. Herndon Avenue, Suite 300, Fresno, California 93711.
Any change to CONTRACTOR’s location of the service site may be made only upon 30 days advance
written notification to COUNTY’s DSS Director and upon written approval from the COUNTY’s DSS
Director or his/her 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, the COUNTY may terminate this Agreement pursuant to
Section 3 of this Agreement.
G. CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, it shall have appropriate staff hired and in place for program services and
operations or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate
this Agreement in accordance with Section 3 of this Agreement.
2. TERM
This Agreement shall be for a term of 1 year and 9 months beginning on October 1, 2015
and ending on June 30, 2017.
This Agreement shall be automatically extended for two additional twelve month periods,
upon the terms and conditions herein set forth, unless written notice of non-renewal is given by either
CONTRACTOR or COUNTY or COUNTY’s DSS Director or designee not later than 60 days prior to
the close of the current Agreement term.
COUNTY OF FRESNO
Fresno, CA
- 3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, is 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 CONTRACTOR thirty (30) days advance written notice.
B. Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of 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 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. The COUNTY shall have the right to demand of the CONTRACTOR the repayment
to the 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. The
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 upon the giving of sixty (60) days
advance written notice of an intention to terminate.
4. COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation based on rates per service modality in accordance with Exhibit B, “Budget,” attached
here to and by this reference incorporated herein. COUNTY agrees to reimburse CONTRACTOR on a
monthly basis, based on units per service. CONTRACTOR agrees to limit administrative cost to a
maximum of 15% of the total program budget and to limit employee benefits to a maximum of 20% of
COUNTY OF FRESNO
Fresno, CA
-4 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
total salaries for those employees working under this Agreement during the term of this Agreement.
Failure to conform to this provision will be grounds for contract termination at the option of the County
of Fresno. Payment shall be made upon certification or other proof satisfactory to COUNTY that
services have actually been performed by CONTRACTOR as specified in this Agreement.
The maximum contract amount for the period of October 1, 2015 through June 30, 2016
shall not exceed Two Million Two Hundred Fifty Thousand and No/100 Dollars ($2,250,000), as
identified in Exhibit B.
For the period of October 1, 2015 through June 30, 2016, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two Million Two Hundred
Fifty Thousand and No/100 Dollars ($2,250,000) in revenue, including Two Million Fifty Thousand
and No/100 Dollars ($2,050,000) in Medi-Cal revenue and Two Hundred Thousand and No/100
Dollars ($200,000) in other revenue sources to offset CONTRACTOR’s program costs, as set forth in
Exhibit B.
The maximum contract amount for the period of July 1, 2016 through June 30, 2017 shall
not exceed Three Million No/100 Dollars ($3,000,000), as identified in Exhibit B.
For the period of July 1, 2016 through June 30, 2017, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Three Million and No/100
Dollars ($3,000,000) in revenue, including Two Million Seven Hundred Thousand and No/100 Dollars
($2,700,000) in Medi-Cal revenue and Three Hundred Thousand and No/100 Dollars ($300,000) in
other revenue sources to offset CONTRACTOR’s program costs, as set forth in Exhibit B.
The maximum contract amount for the period of July 1, 2017 through June 30, 2018 shall
not exceed Three Million and No/100 Dollars ($3,000,000), as set forth in Exhibit B.
For the period of July 1, 2017 through June 30, 2018, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Three Million and No/100
Dollars ($3,000,000) in revenue, including Two Million Seven Hundred Thousand and No/100 Dollars
($2,700,000) in Medi-Cal revenue and Three Hundred Thousand and No/100 Dollars ($300,000) in
other revenue sources to offset CONTRACTOR’s program costs, as set forth in Exhibit B.
The maximum contract amount for the period of July 1, 2018 through June 30, 2019 shall
COUNTY OF FRESNO
Fresno, CA
-5 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
not exceed Three Million and No/100 Dollars ($3,000,000), as set forth in Exhibit B.
For the period of July 1, 2018 through June 30, 2019, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Three Million and No/100
Dollars ($3,000,000) in revenue, including Two Million Seven Hundred Thousand and No/100 Dollars
($2,700,000) in Medi-Cal revenue and Three Hundred Thousand and No/100 Dollars ($300,000) in
other revenue sources to offset CONTRACTOR’s program costs, as set forth in Exhibit B.
In no event shall services performed under this Agreement be in excess of Two Million
Two Hundred Fifty Thousand and No/100 Dollars ($2,250,000) for the period of October 1, 2015
through June 30, 2016. For each subsequent twelve (12) month period of this Agreement, in no event
shall services performed under this Agreement be in excess of Three Million and No/100 Dollars
($3,000,000). The cumulative total of this Agreement shall not be in excess of Eleven Million Two
Hundred Fifty Thousand and No/100 Dollars ($11,250,000). It is understood that all expenses
incidental to CONTRACTOR’s performance of services under this Agreement shall be borne by
CONTRACTOR.
Except as provided below regarding State payment delays, payments by COUNTY shall
be in arrears, for services provided during the preceding month, within forty-five (45) days after
receipt, verification and approval of CONTRACTOR’s invoices by COUNTY’s DSS and/or DBH. If
CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY shall be
relieved of its obligation for further compensation. All final claims 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.
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 COUNTY. The period of
COUNTY OF FRESNO
Fresno, CA
-6 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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.
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 the agreement. At COUNTY’s election, the
disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or shall
be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive
reimbursement for any units of services rendered that are disallowed or denied by the COUNTY
Quality Improvement Committee utilization review process or through State Department of Health
Care Services cost report audit settlement process for Medi-Cal eligible clients.
5.INVOICING
A. At the discretion of COUNTY’s DSS and/or DBH Director or designee, if an
invoice is incorrect or is otherwise not in proper form or substance, COUNTY’s DSS and/or 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’s
satisfaction, COUNTY’s DSS and/or DBH Director or designee may elect to terminate this Agreement,
pursuant to the termination provisions stated in Paragraph 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 Agreement, at the discretion of COUNTY’s DSS and/or DBH Director or designee, COUNTY
shall have the right to deny payment of any additional invoices received.
B.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 Department of Health Care Services (DHCS)
reimbursements for all clients, including those eligible for Medi-Cal as well as those that are not
eligible for Medi-Cal. COUNTY must pay CONTRACTOR before submitting a claim to DHCS for
Federal reimbursement for Medi-Cal eligible clients. CONTRACTOR shall invoice COUNTY by the
COUNTY OF FRESNO
Fresno, CA
-7 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
tenth (10th) day of each month for the prior month’s actual services delivered at the nominal rate
established less any third party funding sources, list clients served by service group and the calculation
of cost per unit.
C.Along with each monthly invoice, CONTRACTOR shall submit a roster
identifying all clients served along with Katie A. class and sub-class members indicated, and provide
demographic information on clients served, including any payer of services rendered to client by
CONTRACTOR.
D.CONTRACTOR shall submit monthly invoicing and general ledger to DBH that
itemizes the line item charges for monthly program costs, and include the cost per unit calculation
based on the number of client served within month. This process will be used to ensure
CONTRACTOR’s program costs are in accordance with the budget and cost per unit by service modes,
as set forth in Exhibit B.
E.CONTRACTOR must report all third party collections from other funding
sources for 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 and any other revenues generated by CONTRACTOR (i.e. private
insurance, etc).
F.CONTRACTOR will remit a schedule annually within ninety (90) days from June
30 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 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.
G.CONTRACTOR shall submit a monthly staffing report that identifies 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 if there a dispute, audit or inspection, until it is resolved, whichever is later. CONTRACTOR
COUNTY OF FRESNO
Fresno, CA
-8 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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. The COUNTY’s electronic billing system is a critical source of information for purposes of
monitoring and obtaining reimbursement. CONTRACTOR must attend COUNTY DBH’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
AVATAR within ten (10) calendar days from the date of services were rendered. The DHCS federal
reimbursement (FFP) 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 in the monthly invoice. State 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.CONTRACTOR must grant security access to required software, to include but
not limited to Java 1.6 update 23 and Netsmart’s custom Crystal Report viewer and AVATAR’s client.
At a minimum CONTRACTORS’ computers must run Windows XP or higher operating system and be
connected to a high speed internet connection. CONTRACTOR shall be responsible for equipment to
support the required software.
M.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
payment/denial or have validation of claiming with no response ninety (90) days after the claim was
COUNTY OF FRESNO
Fresno, CA
-9 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
mailed before the service can be entered into AVATAR. CONTRACTOR must report all third party
collections for Medicare, third party or client pay or private pay in monthly invoice and in the cost
report that is required to be submitted. A copy of explanation of benefits or CWM 1500 is required
as documentation. CONTRACTOR must comply with all laws and regulations governing MediCare
program, including, but not limited to 1) the requirement of the 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 related 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.
N.Data entry shall be the responsibility of the CONTRACTOR. The data for billing
must be reconciled by the CONTRACTOR to the monthly invoice for payment. The 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.
O.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 start of this Agreement through COUNTY to provide
reimbursable services to Medi-Cal eligible 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. Service location must be approved by the COUNTY’s DSS
division. 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.
Medi-Cal billing shall be in accordance with the COUNTY’s Mental Health Plan.
CONTRACTOR must comply with the “Fresno County Mental Health Plan Compliance Program and
COUNTY OF FRESNO
Fresno, CA
-10 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Code of Conduct” set forth in Exhibit C, attached hereto and incorporated herein by reference.
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 COUNTY’s 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
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of 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 their 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 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
COUNTY OF FRESNO
Fresno, CA
-11 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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 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 budget, as set forth in Exhibit B,
that do not exceed ten percent (10%) of the maximum compensation payable to the CONTRACTOR
and changes to the volume of units of services/types of service units to be provided as set forth in
Exhibit B, may be made with the written approval of COUNTY's Department of Social Services
Director and/or Department of Behavioral Health Director or designees and CONTRACTOR. Said
budget line item and 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
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY and CONTRACTOR.
9.HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend 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, their officers, agents or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
///
COUNTY OF FRESNO
Fresno, CA
-12 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
10.INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or
any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and affect the
following insurance policies throughout the term of this Agreement:
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.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-One (21) of this Agreement.
D.Professional Liability
If CONTRACTOR 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.
///
///
COUNTY OF FRESNO
Fresno, CA
-13 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
E.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
F.Sexual Abuse / Molestation Liability
Sexual Abuse / Molestation Liability Insurance (including but not limited to
corporal punishment liability, sexual abuse and molestation liability, and child
abduction liability) with limits of not less than One Million Dollar
($1,000,000.00) per occurrence, Two Million Dollars ($2,000,000.00) annual
aggregate. This policy shall be issued on a per occurrence basis.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
excess only and not contributing with insurance provided under 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, DSS, PO BOX 1912, Fresno,
California, 93718-1912, Attention: Contracts, stating that such insurance coverage 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 COUNTY, its officers, agents and employees, shall be excess only and not contributing
with insurance provided under CONTRACTOR’s policies herein; and that this insurance shall not be
COUNTY OF FRESNO
Fresno, CA
-14 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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, 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 the 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 of Fresno, 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 of the 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 COUNTY’s “Documentation
Standards for Client Records”, attached hereto as Exhibit D and incorporated herein by reference.
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 the State
Department of Health Care Services (DHCS) for the purposes of Short Doyle Medi-Cal
reimbursements and total costs for programs. The cost report will be the source document for several
COUNTY OF FRESNO
Fresno, CA
-15 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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. The CONTRACTOR shall also submit with the cost
report a copy of the CONTRACTOR’S general ledger that supports revenues and expenditures and
reconciled detailed report of reported total units of services rendered under this Agreement to the units
of services reported by CONTRACTOR to COUNTY’S data system.
Cost Reports must be submitted to the COUNTY a hard copy with a signed cover
letter and electronic copy of 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 determine by
State annually. Remit hard copy of cost report to County of Fresno, Attention: Cost Report Team, PO
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 General 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 reimbursement
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
invoicing under compensation until the cost report has been submitted and clear COUNTY desk audit
for completeness.
COUNTY OF FRESNO
Fresno, CA
-16 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
B.Settlements with State Department of Health Care Services (DHCS)
During the term on this Agreement and thereafter, COUNTY and
CONTRACTOR agree to settle dollar amounts disallowed or settled in accordance with DHCS audit
settlement findings related to the Medi-Cal and EPSDT reimbursements. CONTRACTOR will
participate in the several phases of settlements between COUNTY/CONTRACTOR and DHCS. The
phases are initial cost reporting for settlement, settlement according to State reconciliation of records
for paid Medi-Cal services and audit settlement-State DHCS audit. 1) initial cost reporting - after an
internal review by COUNTY, the COUNTY files cost report with State 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 18 to 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; 3) Audit
Settlement-State DHCS audit. After final reconciliation and settlement 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.
Funds owed to COUNTY will be due within 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. Outcome Reports – CONTRACTOR shall submit to COUNTY’s DSS service
outcome reports as requested.
D. Additional Reports -- CONTRACTOR shall submit to COUNTY’s DSS and/or
DBH by the 10th of each month all monthly activity and budget reports for the preceding month.
In addition, CONTRACTOR shall also furnish to COUNTY such statements,
COUNTY OF FRESNO
Fresno, CA
-17 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
records, reports, data, and other information as COUNTY 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.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DSS or DBH staff
and the California Department of Social Services, the right to review and monitor records, programs or
procedures, at any time, in regard to clients, as well as the overall operation of CONTRACTOR’s
programs, 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 the State DHCS, and that under said agreement the State imposes certain requirements
on COUNTY and its subcontractors. CONTRACTOR shall adhere and be responsible for compliance
as of the effective date of each Federal, State or local law or regulation specified , including those
identified in Exhibit E “Mental Health State 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 F: “Medi-Cal Organizational Provider Standards”, attached hereto and incorporated herein. It is
acknowledged that all references to Organizational Provider and/or Provider in Exhibit F shall refer to
CONTRACTOR. In addition, CONTRACTOR shall inform every consumer of their rights as set forth
COUNTY OF FRESNO
Fresno, CA
-18 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
in Exhibit G: “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 consumers, following the Protocol and using the Worksheet identified in Exhibit G.
18.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement 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 ACCOUNTABILITY 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 as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of protected health
information 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 Protected Health Information (PHI) pursuant to the Agreement in compliance with HIPAA, the
Health Information Technology for Economic and Clinical Health Act, Public Law 111-005
(HITECH), and regulations promulgated thereunder by the U.S. Department of Health and Human
Services (HIPAA Regulations) and other applicable laws. As part of the HIPAA 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) of the 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
COUNTY OF FRESNO
Fresno, CA
-19 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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:
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 designees, 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 Chief Information Officer and/or designees.
D.CONTRACTOR may not store COUNTY’s private, confidential or sensitive data
on any hard-disk drive, portable storage devise, or remote storage installation unless encrypted.
E.CONTRACTOR shall be responsible to employ strict controls to ensure the
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.
COUNTY OF FRESNO
Fresno, CA
- 20 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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 responses 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 handicap, medical condition, marital status, age
or sex, pursuant to all applicable State and Federal statutes and regulations.
22. CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility
for planning and carrying out the services provided under this Agreement shall have any direct or
indirect personal financial interest in this Agreement. No officer, agent, or employee of COUNTY who
exercises any function or responsibility for planning and carrying out the services provided under this
Agreement shall have any direct or indirect personal financial interest in this Agreement. In addition,
no employee of COUNTY shall be employed by CONTRACTOR to fulfill any contractual obligations
with COUNTY. CONTRACTOR shall also comply with all Federal, State of California, and local
conflict of interest laws, statutes, and regulations, which shall be applicable to all parties and
beneficiaries under this Agreement and any officer, agent, or employee of COUNTY.
COUNTY OF FRESNO
Fresno, CA
-21 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
23.CHARITABLE CHOICE
CONTRACTOR may not discriminate in its program delivery against a client or potential
client on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal to
actively participate in a religious practice. Any specifically religious activity or service made available
to individuals by CONTRACTOR must be voluntary as well as separate in time and location from
County funded activities and services. CONTRACTOR shall inform COUNTY as to whether it is
faith-based. If CONTRACTOR identifies as faith-based it must submit to DBH and/or DSS a copy of
its policy on referring individuals to an alternate treatment provider, and include a copy of this policy in
its client admission forms. The policy must inform individuals that they may be referred to an
alternative provider if they object to the religious nature of the program, and include a notice to DBH
and/or DSS. Adherence to this policy will be monitored during annual site reviews, and a review of
client files. If CONTRACTOR identifies as faith-based, by July 1 of each year CONTRACTOR will
be required to report to DSS the number of individuals who requested referrals to alternate providers
based on religious objection.
24.ENGLISH PROFICIENCY
CONTRACTOR shall provide 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 documents that contain information that is critical for accessing CONTRACTOR’s
services or are required by law, shall be provided to participants at no cost to the participant.
CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or
translate for a program participant, or who directly communicate with a program participant in a
language other than English, demonstrate proficiency in the participant's language and can effectively
communicate any specialized terms and concepts peculiar to CONTRACTOR’s services.
25.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
COUNTY OF FRESNO
Fresno, CA
-22 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (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
or cost of Ten 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.
26.SINGLE AUDIT CLAUSE
A.If any CONTRACTOR expends Seven Hundred Fifty Thousand 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 must 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 DSS and/or DBH for review within nine (9) months of the 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 OF FRESNO
Fresno, CA
-23 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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.
B.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.
Said audit report shall be delivered to COUNTY’s DBH and/or DSS 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.
C. 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.
27.COMPLIANCE
CONTRACTOR shall comply with the COUNTY’s Contractor Code of Conduct and
Ethics and Compliance Program set forth in Exhibit C. Within thirty (30) days of entering into the
Agreement with the COUNTY, CONTRACTOR shall have all of its 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 additionally ensure that within thirty (30) days of hire, all new employees, agents and
COUNTY OF FRESNO
Fresno, CA
- 24 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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
understands that the promotion of and adherence to the Code of Conduct 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, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within 30 days of hire. Each individual who is
required to attend training shall certify in writing that he or she has received the required training. The
certification shall 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, CA 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.
28. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it is not currently
excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care
Programs: that it has not been convicted of a criminal offense related to the provision of health care
items or services; nor has it been reinstated to participation 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.
COUNTY OF FRESNO
Fresno, CA
-25 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term of this
Agreement, 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 of the charges or
the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
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 a criminal offense related to the provision of health care items or services;
and/or (3) they have been reinstated to participation 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, 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 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 consumers.
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,
COUNTY OF FRESNO
Fresno, CA
- 26 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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 participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
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
provision of health 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 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 the Termination Section 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 consumers.
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.
29. AUDITS AND INSPECTIONS
CONTRACTOR shall at any time during business hours, and as often as the COUNTY
may deem necessary, make available to the COUNTY for examination all of its records and data with
COUNTY OF FRESNO
Fresno, CA
-27 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the
COUNTY, permit the 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).
30.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 of the services described in Section 1 of this Agreement shall be
allowed as necessary to raise public awareness about the availability of such specific services when
approved in advance by COUNTY’s DSS Director or his/her designee and at a cost to be provided in
Exhibit B for such items as written/printed materials, the use of media (i.e., radio, television,
newspapers) and any other related expense(s).
31.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a
consumer or a consumer's family. CONTRACTOR shall provide a copy of the detailed complaint log
entries concerning COUNTY-sponsored consumers to COUNTY at monthly intervals by the tenth
(10th) day of the following month, in a format that is mutually agreed upon. In addition to the detailed
complaint log, CONTRACTOR shall provide details and attach documentation of each complaint with
the log. CONTRACTOR shall post signs informing consumer of their right to file a complaint or
grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to state licensing bodies
that affect COUNTY consumers within twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
consumers, 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.
COUNTY OF FRESNO
Fresno, CA
- 28 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
32. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County Administrative Director
Department of Social Services California Psychological Institute
PO Box 1912 1470 W. Herndon Avenue, Suite 300
Fresno, CA 93718-1912 Fresno, Ca. 93711
Any and all notices between COUNTY and 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.
33. DISCLOSURE – CRIMINAL HISTORY & 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 this 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. With a three-year period preceding their bid proposal, they have had a public
transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR
from further business consideration. The information will be considered as part of the determination of
COUNTY OF FRESNO
Fresno, CA
-29 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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 “Certification Regarding Debarment, Suspension, and Other
Responsibility Matters” in the form set forth in Exhibit H, attached hereto and by this reference
incorporated herein. Additionally, CONTRACTOR must immediately advise the COUNTY in writing
if, during the term of the 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/epls/gov); or (2) any of the above listed conditions
become applicable to CONTRACTOR. CONTRACTOR shall indemnify, defend and hold the
COUNTY harmless for any loss or damage resulting from a conviction, debarment, exclusion,
ineligibility or other matter listed in the signed Certification Regarding Debarment, Suspension, and
Other Responsibility Matters.
34.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 I, attached hereto and by this
reference incorporated herein. The Self-Dealing Transaction Disclosure Form shall be submitted to the
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
///
COUNTY OF FRESNO
Fresno, CA
- 30 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
35. 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 J, “Disclosure
of Ownership and Control Interest Statement”, attached hereto and by this reference incorporated
herein. CONTRACTOR shall submit this form to the Department of Behavioral Health within thirty
(30) days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any
changes to this information within thirty five (35) days of occurrence by completing Exhibit J,
“Disclosure of Ownership and Control Interest Statement.” Submissions shall be scanned pdf copies
and are to be sent via email to DBHAdministration@co.fresno.ca.us attention: Contracts
Administration:
A. Name and address of any person(s) whether it be an individual or corporation
with an ownership or controlling interest in the disclosing entity or managed care entity
1) Address must include the primary business address, every business
location and P.O. Box address(es)
2) Date of birth and Social Security Number for individuals
3) Tax identification number for other corporations or entities with
ownership or controlling interest in the disclosing entity
B. Any subcontractor(s) in which the disclosing entity has five (5) percent or more
interest
C. Whether the person(s) with an ownership or controlling interest of the disclosing
entity is related to another person having ownership or controlling interest as a parent, spouse, sibling
or child. Including whether the person(s) with ownership or controlling interest of the disclosing entity
is related to a person (parent, spouse, sibling or child) with ownership or has five (5) percent or more
interest in any of its subcontractors
COUNTY OF FRESNO
Fresno, CA
-31 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
D.Name of any other disclosing entity in which an owner of the disclosing entity has
an ownership or control interest.
E.The ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the date of the request;
and
F.Any significant business transactions between the provider and any wholly owned
supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of
the request.
G.Any person(s) with an ownership or control interest in the provider, or agent or
managing employee of the provider; and
1)Has been convicted of a criminal offense related to that person's
involvement in any program under Medicare, Medicaid, or the title XX services program since the
inception of those programs.
H.The ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the date of the request;
and
I.Any significant business transactions between the provider and any wholly owned
supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of
the request.
36.GOVERNING LAW
The parties agree that for the purpose of venue, performance under this Agreement is 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.
37.SUPERSEDE
This Agreement shall supersede in its entirety and render null and void the Agreement
between the parties for these same services identified in County Agreement No. A-09-022-3, upon the
effective date of this Agreement.
COUNTY OF FRESNO
Fresno, CA
-32 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
38.ENTIRE AGREEMENT
This Agreement, including all Exhibits, COUNTY’s RFP No. 952-5250, Addendum No.
One (1) to COUNTY’s RFP No. 952-5250, and CONTRACTOR’s Response thereto constitutes the
entire Agreement between CONTRACTOR and COUNTY with respect to the subject matter hereof
and supersedes all previous agreement negotiations, proposals, commitments, writings, advertisements,
publications, and understandings of any nature whatsoever unless expressly included in this
Agreement.
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
3 ATTEST:
4
5
6
7
8
9
10
11
CALIFORNIA PSYCHOLOGICAL
INSTITUTE
By:c:s;D?~
PrintNam~a.uJ Dwhttd ,·
Chairman of Board, or President
12 Or any Vice President
13
14 BybJ~~~-
COUNTY OF FRESNO
Chairman, Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
15
16
17
18
19
20
21
22
23
Print Name: fhl vVtd 1-e Dwh..J ,· Byc:fv l).c~ (~. w"b
Title: 3e.LYe~~ ...
Secretary of Corpora on, or
Any Assistant Secretary, or
Chief Financial Officer, or
24
25
26
27
28
· Any Assistant Treasurer
Mailing Address:
1470 W. Herndon Avenue, Suite 300
Fresno, Ca. 93711
Phone: (559) 256-2000
Contact: Administrative Director
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-33 -COUNTY OF FRESNO
Fresno, CA
Exhibit A
Page 1 of 11
MENTAL HEALTH SERVICES FOR CHILDREN IN CHILD WELFARE
SUMMARY OF SERVICES
ORGANIZATION: California Psychological Institute
ADDRESS: 1470 W. Herndon Avenue, Suite #300
Fresno, CA 93711
TELEPHONE: (559)256-2000
CONTACT PERSON: Michelle Owhadi, Administrative Director
CONTRACT PERIOD: October 1, 2015 – June 30, 2019
CONTRACT AMOUNT: $2,250,000 (October 1, 2015 – June 30, 2016);
$3,000,000 (July 1, 2016 – June 30, 2017);
$3,000,000 (July 1, 2017 – June 30, 2018);
$3,000,000 (July 1, 2018 – June 30, 2019)
SUMMARY OF SERVICES:
California Psychological Institute, henceforth referred to as CONTRACTOR, will be
responsible for providing medically necessary outpatient specialty mental health
services for children and youth with serious emotional disturbance(s) and parents with a
serious mental illness and court-specific services to children and families in Fresno
County’s Child Welfare Services (CWS) system. The majority of outpatient mental
health services, such as assessments, plan development, therapy, rehabilitation
services, crisis intervention, case management, intensive home based services and
intensive care coordination are expected to be community-based and provided in the
family’s home or in the community when possible. For those services provided in the
office, CONTRACTOR will work closely with the caregiver to identify and assist,
whenever possible, with any barriers to receiving care (i.e., lack of public/private
transportation, scheduling of appointment days/hours, etc.).
SCHEDULE OF SERVICES:
The CONTRACTOR’S office(s) shall be open Monday through Thursday, 7:30am to
7:00pm and Friday to Saturday, 8:00am to 5:00pm. Clinicians will be available to see
clients and families for in-home appointments during the day, weekend, and evening
hours, up to 7:00 pm. Group services will be provided during the day and evening
hours, up to 7:00 pm, on a scheduled basis, at CONTRACTOR’S offices. The
CONTRACTOR’s office will be located at a site in the metropolitan or rural community
that offers public transportation in close proximity, adequate parking, and in a secure
setting. In addition to the Fresno metropolitan area, CONTRACTOR has agreed to
serve the rural areas of Fresno County as needed. Any addition or change to the
location of office-based services must be approved by the COUNTY in advance of such
a change.
Exhibit A
Page 2 of 11
TARGET POPULATION:
CONTRACTOR shall provide mental health services to all referred children, youth,
parents, guardians, and foster parents involved with a child’s CWS case. The target
population includes children and youth as referred to in the Katie A. Settlement
Agreement as members of the “class” and “subclass.”
1.Katie A. “Class” is defined as children in California who:
A.Are in foster care or are at imminent risk of foster care placement, and
B.Have a mental illness or condition that has been documented, or would
have been documented had an assessment been conducted, and
C.Need individualized mental health services, including but not limited to,
professionally acceptable assessments, behavioral support, case
management, family support, crisis support, therapeutic foster care, and
other medically necessary services in the home or in a home-like setting,
to treat mental illness or condition.
Imminent Risk of foster care placement means that within the last 180 days, the child
has been participating in voluntary family maintenance services; voluntary family
reunification placements; and/or has been the subject of a referral/report to the Child
Protective Services system regarding suspicions of abuse, neglect or abandonment.
Members of this class include children living with their parents, relatives, or in any
variety of placements, such as group homes or foster homes.
2.Katie A. “Subclass” is identified as children in California who:
A.Have an open child welfare service case; and
B.Are full-scope Medi-Cal (Title XIX) eligible; and
C.Meet the medical necessity criteria for Medi-Cal Outpatient Specialty
Mental Health Services (SMHS) as set forth in CCR, Title 9, Section
1830.205 or Section 1830.210; and
D.Currently in or being considered for wraparound, therapeutic foster care,
specialized care rate due to behavioral health needs or other intensive
Early and Periodic Screening Diagnostic and Treatment (EPSDT)
services, including but not limited to therapeutic behavioral services or
crisis stabilization/intervention, or
E.Currently in or being considered for placement in a group home (Rate
Classification 10 or above), a psychiatric hospital or 24-hour mental health
Exhibit A
Page 3 of 11
treatment facility (e.g., psychiatric inpatient hospital, community residential
treatment facility); or has experienced three or more placements within 24
months due to behavioral health needs
I. CONTRACTOR SHALL BE RESPONSIBLE FOR THE FOLLOWING SERVICES:
A. Outpatient Specialty Mental Health Services
1. CONTRACTOR will provide the following array of outpatient specialty
mental health services for the duration, frequency and intensity based
upon the individual needs of children and families in CWS and
determined to be clinically appropriate as determined by a
licensed/waivered mental health clinician. It is understood that a child
who meets the definition of “Katie A. Subclass” does not, in and of
itself, require a higher level or intensity of mental health treatment
absent a clinical determination by the treating mental health clinician:
a. Mental Health Assessments
Clinical analysis of the history and current status of a
beneficiary’s mental, emotional, or behavioral disorder;
relevant cultural issues and history; diagnosis; and use of
testing procedures.
b. Therapy
1. A therapeutic intervention that focuses primarily on
symptom reduction as a means to improve functional
impairments. Therapy may be delivered to an individual
or group of beneficiaries (see below) and may include
family therapy at which the beneficiary is present.
a. Individual
b. Collateral
c. Conjoint
d. Family therapy
e. Group therapy
i. Groups will be led by clinicians and
supervised by a licensed clinician. Larger
groups may be co-facilitated by two
unlicensed clinicians. Licensed Clinical
Supervisors will provide in-vivo training, co-
facilitation and supervision to ensure group
facilitation is high quality, clinically effective,
and appropriate.
c. Crisis Intervention
A service lasting less than 24 hours, to or on behalf of a
beneficiary for a condition which requires more timely
response than a regularly scheduled visit. Activities may
include, but are not limited to assessment, therapy and
service access to any significant support person in the
Exhibit A
Page 4 of 11
beneficiary’s life with the intent of improving or
maintaining the mental health status of the beneficiary.
d. Case Management
Any service that assists a beneficiary to access needed
medical, educational, social, prevocational, vocational,
rehabilitative, or other community service. Services may
include, but are not limited to, communication,
coordination, and referral to available resources.
CONTRACTOR will be responsible for monitoring service
delivery to beneficiary by third parties, beneficiary
progress and plan development.
e. Rehabilitation
Any activity that seeks to improve, maintain, or restore a
beneficiary’s functional, daily living, social, leisure,
grooming, personal hygiene, and meal preparation skills
while also providing access to support resources and
medication education.
f. Plan Development
The development of client plans, approval of client plans,
or monitoring of a beneficiary’s progress.
g. Medication Support
Any service that includes prescribing, administering,
dispensing and monitoring psychiatric medications or
biologicals which are necessary to alleviate the
symptoms of mental illness. Services may also include
evaluation for the need of medication, evaluation of
clinical effectiveness and side effects, obtaining informed
consent, medication education and plan development
related to the delivery of the service and/or assessment
of the beneficiary.
2. CONTRACTOR shall be responsible to provide and appropriately bill
for Katie A. Subclass members if medically necessary and provided
within the CAPP and Katie A. Core Practice Model and in accordance
with the “Medi-Cal Manual for Intensive Care Coordination (ICC),
Intensive Home Based Services (IHBS) & Therapeutic Foster Care
(TFC) for Katie A. Subclass Members”:
a. Intensive Home Based Services (IHBS) may include, but are
not limited to:
1. Skill-based interventions for the remediation of behaviors
or improvement of symptoms,
2. Development of functional skills to improve self-care,
self-regulation, or other functional impairments by
intervening to decrease or replace non-functional
behavior that interferes with daily living tasks or the
avoidance of exploitation by others
3. Development of skills or replacement behaviors that
allow the child/youth to fully participate in the teaming
Exhibit A
Page 5 of 11
process and service plans including but not limited to the
plan and/or child welfare case plan
4. Improvement in self-management of symptoms, including
self-administration of medications as appropriate
5. Education of the child/youth and/or their family or
caregiver(s) about, and how to manage the child/youth’s
mental health disorder or symptoms
6. Support of the development, maintenance and use of
social networks including the use and natural and
community resources
7. Support to address behaviors that interfere with the
achievement of a stable and permanent family life
8. Support to address behaviors that interfere with seeking
and maintains a job
9. Support to address behaviors that interfere with a
child/youth’s success in achieving educational objectives
in an academic program in the community
b. Intensive Care Coordination (ICC) that requires active and
ongoing participation in any teaming processes scheduled
by CWS or by the Child Welfare Mental Health Team to
insure coordination of all mental health treatment services
that may involve one or more provider agency(ies).
c. ICC service components/activities include comprehensive
assessment and periodic reassessment, development and
periodic revision of the plan, referral, monitoring and follow-
up activities and transition.
3. CONTRACTOR will be responsible to work cooperatively and
collaboratively with CWS staff, Child Welfare Mental Health Program
staff and all treatment providers, caregivers, and Foster Family
Agencies to achieve the individual and collective treatment goals and
support the CWS case plan, communicate/resolve barriers to care,
provide continuity and warm-handoffs whenever possible when clients
transition from higher to lower or lower to higher levels of care whether
within or outside of Fresno County.
4. CONTRACTOR will provide its service delivery model for Katie A.
class and subclass members from which the revenue projections were
budgeted. This includes the frequency/duration of interventions during
a specified timeframe from which COUNTY will monitor utilization and
potential service capacity.
5. CONTRACTOR will be able to refer to other Fresno County Mental
Health Plan providers, Managed Care Medi-Cal Health Plans and other
community providers as may be appropriate and concurrence with the
CWMH program.
6. CONTRACTOR will identify evidence-based and/or best practices
found effective in serving this target population. This includes the
provision of training, ongoing sustainability and fidelity to a core
competency to CONTRACTOR’S mental health clinicians. To date,
CONTRACTOR and COUNTY have agreed upon the provision of the
Exhibit A
Page 6 of 11
following evidence-based practices: Dialectical Behavioral Therapy
(DBT), Motivational Interviewing (MI), Nurturing Parenting Programs,
Circle of Security (COS), Trauma-Focused Cognitive-Behavioral
Therapy (TF-CBT), Trauma-Focused Integrated Play Therapy, Child-
Centered Play Therapy (CCPT), Child-Parent Psychotherapy (CPP),
Theraplay, Attachment-Focused Family Therapy (AFFT), Brief
Strategic Family Therapy, Dyadic Developmental Psychotherapy
(DDP), and Filial Therapy. This does not exclude other evidence-
based, best or promising practice or therapeutic approaches that
clinicians may have proficiency and meets the individualized treatment
needs of the client. Any additions or deletions of previous COUNTY
approved evidence-based practice by CONTRACTOR will require
consultation with COUNTY.
7. CONTRACTOR will ensure that the Clinical Supervisors will oversee
the work of the Clinicians, including approving documentation and
claiming in Electronic Medical Records. The Clinical Supervisor will be
two years post license and able to provide Board of Behavioral
Sciences (BBS) supervision.
8. If CONTRACTOR has other agreements with COUNTY to provide
mental health treatment services, it will establish criteria and protocols
to insure referral to services are therapeutically appropriate, benefits
the client and caregiver, achieves the client’s treatment goals and
supports the success of the CWS case plan and avoids any potential
for perceived or actual conflict of interest or self-referral.
B. Affordable Care Act and Medi-Cal Managed Care Plan requirements
1. CONTRACTOR understands that effective January 1, 2014, Medi-Cal
managed care health plans (MCPs) are required to serve Medi-Cal
beneficiaries with mild to moderate impairment of mental, emotional, or
behavioral functioning resulting from a mental health condition defined
by the current Diagnostic and Statistical Manual. Outpatient benefits
available through MCPs include:
a. Individual and group mental health evaluation and treatment
(psychotherapy)
b. Psychological testing, when clinically indicated to evaluate a
mental health condition;
c. Outpatient services for the purposes of monitoring drug
therapy;
d. Psychiatric consultation; and,
e. Outpatient laboratory, drugs, supplies and supplements
(excluding medications as described in the forthcoming
“Medi-Cal Managed Care Plan Responsibilities for
Outpatient Mental Health Services and Coordination with
County Mental Health Plans”)
2. CONTRACTOR will comply with all requirements established by the
Department of Health Care Services, Fresno County Mental Health
Exhibit A
Page 7 of 11
Plan and MCPs for screening, referral, and coordination of care when
clinically appropriate.
C. Court-Specific Mental Health Services
1. CONTRACTOR will provide the following court-ordered mental health
services to children and families in CWS:
a. Court-Ordered Mental Health Assessments
Clinical analysis of the history and current status of a
beneficiary’s mental, emotional, or behavioral disorder;
relevant cultural issues and history; diagnosis; and use of
testing procedures.
b. Psychological and Neuropsychological Evaluations
A structured, analytical interview with the client, minor,
parent, or guardian, which consists of a clinical
assessment, the use of testing instruments, a mental
status examination, and a clinical diagnosis (as
defined/ruled out using the ICD-10) that is performed only
by a Licensed Psychologist with at least 5 years of
postgraduate experience. Service also includes a review
of CPS and mental health services received to date and
contact with relevant others as necessary/possible. A
second psychological or neuropsychological evaluation
may be ordered and must be performed by a different
Licensed Psychologist and independent of the first
evaluation.
c. Bonding Studies
A structured, forensic, analytic interview that includes a
mental health assessment (define or rule out clinical
diagnosis using the ICD-10) for both parent(s) or
whomever has been identified by the court to participate
in the study, and the child(ren). The study includes
assessment of the interaction between the parent(s) and
the child(ren) and may include the use of testing
instruments (as needed) to more accurately gauge the
strength of the bond between parent and child. It may
also include the current care provider(s) or prospective
adoptive parent(s) when ordered by the court. These
studies are to be performed only by a Licensed Mental
Health Clinician with appropriate experience or a
Waivered Psychologist working under a qualified
Licensed Psychologist. A qualified clinician will have
completed 20 hours of training in Child Custody as
required by the California Board of Psychology (if the
child is 0-36 months), training in the Marshak Interaction
Method, and training or experience in providing forensic
evaluations for the court.
Exhibit A
Page 8 of 11
d.Family Psychodynamic Formulation
A structured, analytical interview conducted by a
Licensed Mental Health Clinician or Waivered
Psychologist if under the supervision of a Licensed
Psychologist, which consists of a clinical assessment
(define or rule out clinical diagnosis using the ICD-10)
and family session(s) with all relevant family members, to
identify the roles inhabited by the members and their
interactive patterns. Also includes a review of all
available CPS and mental health interviews with relevant
professionals (CPS, school personnel, therapists, etc.).
e. Attachment Assessments
A structured, analytical interview performed only by a
licensed Mental Health Clinician with appropriate
experience that includes a clinical assessment of the
interaction between the parent/caregiver(s) and the child.
Infant Family Mental Health (IFMH) training is required if
any of the children are 0-36 months. Testing instruments
may be used as needed to more accurately gauge the
strength and quality of the attachment between parent
and child.
2.CONTRACTOR will be responsible for any court reports and/or
necessary testimony.
a.Court Reports
Documented report of assessment and evaluation
findings, progress in treatment, recommendations for
treatment and service plan regarding reunification,
maintenance and termination of parental rights, and
justification for recommendations.
b.Court Testimony
On-site court testimony of assessment and evaluation
findings, treatment and service plan recommendations
regarding reunification, maintenance and termination of
parental rights, and justification for recommendations.
D.Program Evaluation
1.Meet with COUNTY staff monthly or as often as needed for monitoring
of program services, client capacity, staffing levels and to exchange
pertinent operational information, resolve problems, and coordinate
services.
2.CONTRACTOR will adhere to the outcome measures developed by
COUNTY and any requirements established by the California
Department of Social Services and the California Department of Health
Services.
Exhibit A
Page 9 of 11
E.Data and Reporting
1.Maintain and provide the COUNTY monthly with statistics on the
number of individuals/families to include:
a.Number of clients referred for mental health
assessments; average time between referral and the
contact with caregiver; average time between referral and
the assessment; number completed, number of
missed/no show appointments, number that did not meet
Medi-Cal medical necessity criteria
b.Number of clients referred for court-ordered services
including type of service, average time between referral
to contact with the caregiver to schedule the
appointment, average number of days between the
referral and the court-ordered service, number of
missed/no show appointments
c.Average wait time between assessment and first visit
with assigned therapist
d.Average wait time between referral and provision of
medication evaluation
e.Unique clients served; units and dollars of services billed,
average cost per client
f.Number and reasons for discharge from care
g.Current number of active clients in ongoing treatment
h.Total number of positions by discipline in the approved
budget, number of staff hired (including licensure,
ethnicity, bilingual language capability, clinical
training/certification in evidence-based practice(s) and
number of vacancies
(This information, in addition to the outcome measures to be
developed, will be provided to COUNTY monthly via an activity report
template developed by the COUNTY).
2.Maintain case files on each individual/family, including, but not limited
to the following information:
a.Documentation of referrals to/from COUNTY, self-referrals and
others;
b.Chronological record of individual and family services provided
including relevant contact dates, incidents, actions taken, and
results; and,
c.Case closure summary, indicating the reasons for closure and
the results of the services provided.
3.Maintain secure case files with limited access only to designated staff
to ensure confidentiality.
Exhibit A
Page 10 of 11
4.Submit a monthly activity report providing data on various case status,
etc . This report will be due no later than the 10th of each month.
II.COUNTY SHALL BE RESPONSIBLE FOR THE FOLLOWING:
A.Provide mental health service referrals to CONTRACTOR for children and
families in CWS.
B.Designate a contact person for CONTRACTOR to communicate with when
necessary.
C.Meet with CONTRACTOR monthly or as often as needed, to exchange pertinent
information, resolve problems, and work together to coordinate referrals and
services.
D.Support coordination of Intensive Care Coordination meetings initially and no
less than every 90 days for a child/youth identified as a Katie A. Subclass
member
E.Convene team meetings in alignment with California Partners for Permanency
(CAPP), Senate Bill 163 Wraparound, and Katie A. Core Practice models for
which CONTRACTOR will be required to participate when appropriate
F.Provide education and training on CWS, practice models and Medi-Cal licensing,
documentation and billing requirements as needed
III.PERFORMANCE MEASUREMENTS
Overall Service Objective:
Services provided by the CONTRACTOR will align and support the principles of
Fresno’s child welfare practice model, the Katie A Settlement Agreement, and the
Senate Bill 163 Wraparound family-based service program.
Mental Health Services will be integrated, timely, ongoing and uninterrupted in a family-
focused, trauma-informed delivery model that supports the goals of the client plan
developed by COUNTY. Intensive home-based mental health services are expected to
provide children and families in the CWS system with effective treatment, improve
outcomes, promote wellness, aid in resiliency, and maintain family relationships
conducive to healthy emotional development.
Performance Outcomes and Measures:
Under the Katie A. Settlement Agreement and Implementation Plan, the California
Departments of Health Care Services (DHCS) and Social Services (CDSS) are working
to adopt statewide use of a data-informed system of performance oversight,
accountability, and communication that efficiently monitors, measures, and evaluates
Exhibit A
Page 11 of 11
access, quality, satisfaction, effectiveness, costs, and outcomes at the individual,
program, and system levels.
Performance measurements developed by COUNTY will reflect the information
required by DHCS and CDSS. Outcome indicators for this Agreement will include but
not be limited to tracking trends of penetration rates, number of clients, wait times,
treatment duration, types of service, success rates, reunification rates, etc. These
indicators will continue to be developed in conjunction with CONTRACTOR, County,
and State departments.
Exhibit B
Page: 1 of 8
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Clinical Director 1.00 $93,150 $93,150
0002 Psychiatrist 0.40 $109,200 $109,200
0003 Clinicians (Licensed)5.00 $284,625 $284,625
0004 Psychologist 0.50 $56,250 $56,250
0005 Clinicians( Interns)6.00 $290,250 $290,250
0006 Rehab Specialist 8.00 $241,200 $241,200
0007 Case Manager/Dr. Assistant 2.00 $68,925 $68,925
0008 Support Staff/Admin 7.00 $337,500 $337,500
SALARY TOTAL 29.90 $337,500 $1,143,600 $1,481,100
PAYROLL TAXES:
0030 OASDI $85,058
0031 FICA/MEDICARE $19,893
0032 U.I./FUTA $9,946
PAYROLL TAX TOTAL $0 $0 $114,897
EMPLOYEE BENEFITS:
0039 Retirement/Incentive $44,997
1170 Workers Compensation $9,750
0041 $131,250
EMPLOYEE BENEFITS TOTAL $0 $0 $185,997
SALARY & BENEFITS GRAND TOTAL $1,781,994
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $199,556
1030 Rent/Lease Equipment $750
1050 Utilities $22,500
1052 Janitorial $22,500
1051 Maintenance (facility)$7,500
FACILITY/EQUIPMENT TOTAL $252,806
OPERATING EXPENSES:
1060 $19,575
1062 $1,125
1070 $4,500
1071 $270
1072 $4,125
1080 Office Supplies & Equipment $12,375
1090 $6,750
1100 Food $7,125
1120 Program Supplies $6,375
1121 Program Supplies - Psych Testing $2,250
1130 $375
1140 $63,356
1141 $6,000
1075 $0
1076 Licenses/Taxes $3,750
1077 Other - Provide Brief Description $0
OPERATING EXPENSES TOTAL $137,951
Child Welfare Mental Health Services
California Psychological Institute
Budget - Oct 1, 2015 to June 30, 2016
Publications
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Telephone/Internet
Health Insurance (medical vision, life, dental)
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
Exhibit B
Page: 2 of 8
Child Welfare Mental Health Services
California Psychological Institute
Budget - Oct 1, 2015 to June 30, 2016
FINANCIAL SERVICES EXPENSES:
1160 Accounting/Bookkeeping $5,625
1171 Liability Insurance $18,000
1072 Payroll Processing $17,250
FINANCIAL SERVICES TOTAL $40,875
SPECIAL EXPENSES (Consultant/Etc.):
1153 Consultant (network & data management)$11,250
1180 Translation Services $375
1085 Electronic Health Record $15,750
SPECIAL EXPENSES TOTAL $27,375
FIXED ASSETS:
2001 Computers & Software $5,250
2002 Furniture & Fixtures $3,750
FIXED ASSETS TOTAL $9,000
TOTAL PROGRAM EXPENSES $2,250,000
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services 611,168 $2.61 $1,595,149
(Assessment, Plan of Care, Individual/Family/Group Therapy, Re 0 $0
3100 Case Management, Linkage/Brokerage 228,437 $2.02 $461,443
3200 Crisis Intervention 1,200 $3.88 $4,656
3300 Medication Support 18,000 $4.82 $86,760
3400 Collateral 16,500 $2.61 $43,065
3700 ICC 150 $2.02 $303
3800 IHBS 150 $2.02 $303
3900 other 0 $0.00 $0
DIRECT SERVICE REVENUE TOTAL 875,606 $2,191,679
$1,025,000
$820,000
$205,000
$2,050,000
Cost Per Unit $2.50
OTHER REVENUE:
3600 Psychological evaluation 15,750 $2.61 $41,108
3500 Court Documentation, Report, Appearance 53 $59.41 $3,119
4000 Bonding Studies 5,400 $2.61 $14,094
4100 Non Medi-Cal contribution $141,679
4200 Other $0
4300 Other $0
OTHER REVENUE/SOCIAL SERVICES TOTAL 21,203 $200,000
TOTAL PROGRAM REVENUE $2,250,000
Medi-cal Revenue - 50% FFP
Medi-cal Revenue - 40% EPSDT
Medi-cal Revenue - 10% CGF
Medi-cal Revenue
Exhibit B
Page: 3 of 8
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Clinical Director 1.00 $124,200 $124,200
0002 Psychiatrist 0.40 $145,600 $145,600
0003 Clinicians (Licensed)5.00 $379,500 $379,500
0004 Psychologist 0.50 $75,000 $75,000
0005 Clinicians( Interns)6.00 $387,000 $387,000
0006 Rehab Specialist 8.00 $321,600 $321,600
0007 Case Manager/Dr. Assistant 2.00 $91,900 $91,900
0008 Support Staff/Admin 7.00 $450,000 $450,000
SALARY TOTAL 29.90 $450,000 $1,524,800 $1,974,800
PAYROLL TAXES:
0030 OASDI $113,410
0031 FICA/MEDICARE $26,523
0032 U.I./FUTA $13,262
PAYROLL TAX TOTAL $0 $0 $153,196
EMPLOYEE BENEFITS:
0040 Retirement/Incentive $60,996
1170 Workers Compensation $13,000
0041 $175,000
EMPLOYEE BENEFITS TOTAL $0 $0 $248,996
SALARY & BENEFITS GRAND TOTAL $2,376,992
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $266,075
1030 Rent/Lease Equipment $1,000
1050 Utilities $30,000
1052 Janitorial $30,000
1051 Maintenance (facility)$10,000
FACILITY/EQUIPMENT TOTAL $337,075
OPERATING EXPENSES:
1060 $26,100
1062 $1,500
1070 $6,000
1071 $360
1072 $5,500
1080 Office Supplies & Equipment $16,500
1090 $9,000
1100 Food $9,500
1120 Program Supplies $8,500
1121 Program Supplies - Psych Testing $3,000
1130 $500
1140 $84,474
1141 $7,000
1075 $0
1076 Licenses/Taxes $5,000
1077 Other - Provide Brief Description $0
OPERATING EXPENSES TOTAL $182,934
Transportation of Clients
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Training/Registration
Staff Mileage/vehicle maintenance
Child Welfare Mental Health Services
California Psychological Institute
Budget - July 1, 2016 to June 30, 2017
Publications
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Telephone/Internet
Health Insurance (medical vision, life, dental)
Exhibit B
Page: 4 of 8
Child Welfare Mental Health Services
California Psychological Institute
Budget - July 1, 2016 to June 30, 2017
FINANCIAL SERVICES EXPENSES:
1160 Accounting/Bookkeeping $7,500
1171 Liability Insurance $24,000
1072 Payroll Processing $23,000
FINANCIAL SERVICES TOTAL $54,500
SPECIAL EXPENSES (Consultant/Etc.):
1153 Consultant (network & data management)$15,000
1180 Translation Services $500
1085 Electronic Health Record $21,000
SPECIAL EXPENSES TOTAL $36,500
FIXED ASSETS:
2001 Computers & Software $7,000
2002 Furniture & Fixtures $5,000
FIXED ASSETS TOTAL $12,000
TOTAL PROGRAM EXPENSES $3,000,000
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services 814,891 $2.61 $2,126,866
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage 304,583 $2.02 $615,258
3200 Crisis Intervention 1,600 $3.88 $6,208
3300 Medication Support 24,000 $4.82 $115,680
3400 Collateral 22,000 $2.61 $57,420
3700 ICC 200 $2.02 $404
3800 IHBS 200 $2.02 $404
3900 other $0
DIRECT SERVICE REVENUE TOTAL 1,167,474 $2,922,239
$1,350,000
$1,080,000
$270,000
$2,700,000
Cost Per Unit 2.50
OTHER REVENUE:
3600 Psychological evaluation 21,000 2.61$ $54,810
3500 Court Documentation, Report, Appearance 70 59.41$ $4,159
4000 Bonding Studies 7200 2.61$ $18,792
4100 Non Medi-Cal contribution $222,239
4200 Other $0
4300 Other $0
OTHER REVENUE/SOCIAL SERVICES TOTAL 28,270 $300,000
Medi-cal Revenue
Medi-cal Revenue - 50% FFP
Medi-cal Revenue - 40% EPSDT
Medi-cal Revenue - 10% CGF
Exhibit B
Page: 5 of 8
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Clinical Director 1.00 $128,547 $128,547
0002 Psychiatrist 0.40 $145,600 $145,600
0003 Clinicians (Licensed)5.00 $387,500 $387,500
0004 Psychologist 0.50 $75,000 $75,000
0005 Clinicians( Interns)6.00 $387,000 $387,000
0006 Rehab Specialist 8.00 $321,600 $321,600
0007 Case Manager/Dr. Assistant 2.00 $93,738 $93,738
0008 Support Staff/Admin 7.00 $450,000 $450,000
SALARY TOTAL 29.90 $450,000 $1,538,985 $1,988,985
PAYROLL TAXES:
0030 OASDI $114,290
0031 FICA/MEDICARE $26,729
0032 U.I./FUTA $13,365
PAYROLL TAX TOTAL $0 $0 $154,383
EMPLOYEE BENEFITS:
0040 Retirement/Incentive $48,623
1170 Workers Compensation $13,000
0041 $175,000
EMPLOYEE BENEFITS TOTAL $0 $0 $236,623
SALARY & BENEFITS GRAND TOTAL $2,379,991
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $266,075
1030 Rent/Lease Equipment $1,000
1050 Utilities $30,000
1052 Janitorial $30,000
1051 Maintenance (facility)$15,000
FACILITY/EQUIPMENT TOTAL $342,075
OPERATING EXPENSES:
1060 $26,100
1062 $1,500
1070 $11,000
1071 $360
1072 $3,000
1080 Office Supplies & Equipment $14,000
1090 $9,000
1100 Food $8,500
1120 Program Supplies $8,500
1121 Program Supplies - Psych Testing $3,000
1130 $500
1140 $84,474
1141 $7,000
1075 $0
1076 Licenses/Taxes $5,000
1077 Other - Provide Brief Description $0
OPERATING EXPENSES TOTAL $181,934
Transportation of Clients
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Training/Registration
Staff Mileage/vehicle maintenance
Child Welfare Mental Health Services
California Psychological Institute
Budget - July 1, 2017 to June 30, 2018
Publications
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Telephone/Internet
Health Insurance (medical vision, life, dental)
Exhibit B
Page: 6 of 8
Child Welfare Mental Health Services
California Psychological Institute
Budget - July 1, 2017 to June 30, 2018
FINANCIAL SERVICES EXPENSES:
1160 Accounting/Bookkeeping $7,500
1171 Liability Insurance $24,000
1072 Payroll Processing $23,000
FINANCIAL SERVICES TOTAL $54,500
SPECIAL EXPENSES (Consultant/Etc.):
1153 Consultant (network & data management)$13,000
1180 Translation Services $500
1085 Electronic Health Record $21,000
SPECIAL EXPENSES TOTAL $34,500
FIXED ASSETS:
2001 Computers & Software $5,000
2002 Furniture & Fixtures $2,000
FIXED ASSETS TOTAL $7,000
TOTAL PROGRAM EXPENSES $3,000,000
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services 814,891 $2.61 $2,126,866
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage 304,583 $2.02 $615,258
3200 Crisis Intervention 1,600 $3.88 $6,208
3300 Medication Support 24,000 $4.82 $115,680
3400 Collateral 22,000 $2.61 $57,420
3700 ICC 200 $2.02 $404
3800 IHBS 200 $2.02 $404
3900 other $0
DIRECT SERVICE REVENUE TOTAL 1,167,474 $2,922,239
$1,350,000
$1,080,000
$270,000
$2,700,000
Cost Per Unit 2.50
OTHER REVENUE:
3600 Psychological evaluation 21,000 2.61$ $54,810
3500 Court Documentation, Report, Appearance 70 59.41$ $4,159
4000 Bonding Studies 7200 2.61$ $18,792
4100 Non Medi-Cal contribution $222,239
4200 Other $0
4300 Other $0
OTHER REVENUE/SOCIAL SERVICES TOTAL $300,000
Medi-cal Revenue
Medi-cal Revenue - 50% FFP
Medi-cal Revenue - 40% EPSDT
Medi-cal Revenue - 10% CGF
Exhibit B
Page: 7 of 8
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Clinical Director 1.00 $128,547 $128,547
0002 Psychiatrist 0.40 $145,600 $145,600
0003 Clinicians (Licensed)5.00 $387,500 $387,500
0004 Psychologist 0.50 $75,000 $75,000
0005 Clinicians( Interns)6.00 $387,000 $387,000
0006 Rehab Specialist 8.00 $321,600 $321,600
0007 Case Manager/Dr. Assistant 2.00 $93,738 $93,738
0008 Support Staff/Admin 7.00 $450,000 $450,000
SALARY TOTAL 29.90 $450,000 $1,538,985 $1,988,985
PAYROLL TAXES:
0030 OASDI $114,290
0031 FICA/MEDICARE $26,729
0032 U.I./FUTA $13,365
PAYROLL TAX TOTAL $0 $0 $154,383
EMPLOYEE BENEFITS:
0040 Retirement/Incentive $54,623
1170 Workers Compensation $13,000
0041 $175,000
EMPLOYEE BENEFITS TOTAL $0 $0 $242,623
SALARY & BENEFITS GRAND TOTAL $2,385,991
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $266,075
1030 Rent/Lease Equipment $1,000
1050 Utilities $30,000
1052 Janitorial $30,000
1051 Maintenance (facility)$15,000
FACILITY/EQUIPMENT TOTAL $342,075
OPERATING EXPENSES:
1060 $26,100
1062 $1,500
1070 $11,000
1071 $360
1072 $3,000
1080 Office Supplies & Equipment $14,000
1090 $9,000
1100 Food $8,500
1120 Program Supplies $8,500
1121 Program Supplies - Psych Testing $3,000
1130 $500
1140 $84,474
1141 $5,000
1075 $0
1076 Licenses/Taxes $5,000
1077 Other - Provide Brief Description $0
OPERATING EXPENSES TOTAL $179,934
Lodging
Legal Notices/Advertising
Household Supplies
Transportation of Clients
Staff Mileage/vehicle maintenance
Staff Training/Registration
Health Insurance (medical vision, life, dental)
Telephone/Internet
Postage
Printing/Reproduction
Publications
Child Welfare Mental Health Services
California Psychological Institute
Budget - July 1, 2018 to June 30, 2019
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Exhibit B
Page: 8 of 8
Child Welfare Mental Health Services
California Psychological Institute
Budget - July 1, 2018 to June 30, 2019
FINANCIAL SERVICES EXPENSES:
1160 Accounting/Bookkeeping $7,500
1171 Liability Insurance $24,000
1072 Payroll Processing $23,000
FINANCIAL SERVICES TOTAL $54,500
SPECIAL EXPENSES (Consultant/Etc.):
1153 Consultant (network & data management)$13,000
1180 Translation Services $500
1085 Electronic Health Record $21,000
SPECIAL EXPENSES TOTAL $34,500
FIXED ASSETS:
2001 Computers & Software $2,000
2002 Furniture & Fixtures $1,000
FIXED ASSETS TOTAL $3,000
TOTAL PROGRAM EXPENSES $3,000,000
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services 814,891 $2.61 $2,126,866
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage 304,583 $2.02 $615,258
3200 Crisis Intervention 1,600 $3.88 $6,208
3300 Medication Support 24,000 $4.82 $115,680
3400 Collateral 22,000 $2.61 $57,420
3700 ICC 200 $2.02 $404
3800 IHBS 200 $2.02 $404
3900 other $0
DIRECT SERVICE REVENUE TOTAL 1,167,474 $2,922,239
$1,350,000
$1,080,000
$270,000
$2,700,000
Cost Per Unit 2.50
OTHER REVENUE:
3600 Psychological evaluation 21,000 2.61$ $54,810
3500 Court Documentation, Report, Appearance 70 59.41$ $4,159
4000 Bonding Studies 7200 2.61$ $18,792
4100 Non Medi-Cal contribution $222,239
4200 Other $0
4300 Other $0
OTHER REVENUE/SOCIAL SERVICES TOTAL $300,000
TOTAL PROGRAM REVENUE $3,000,000
Medi-cal Revenue - 10% CGF
Medi-cal Revenue
Medi-cal Revenue - 50% FFP
Medi-cal Revenue - 40% EPSDT
Exhibit C
Page 1 of 3
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 of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5.Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6.Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7.Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit C
Page 2 of 3
8.Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9.Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11.Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit C
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
Exhibit D
Page 1 of 3
0374 d dbh
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified and
updated as appropriate.
• Presenting problems and relevant conditions affecting the client’s physical health and mental
health status will be documented, for example: living situation, daily activities, and social
support.
• Documentation will describe client’s strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently documented
and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates, providers,
therapeutic interventions and responses, sources of clinical data, relevant family information and
relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as well as
illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A five axis diagnosis from the most current DSM, or a diagnosis from the most current ICD,
will be documented, consistent with the presenting problems, history mental status evaluation
and/or other assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in the
client’s condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B. Client Plans
1. Client plans will:
Exhibit D
Page 2 of 3
0374 d dbh
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
* the person providing the service(s), or
* a person representing a team or program providing services, or
* a person representing the MHP providing services
* when the client plan is used to establish that the services are provided under the direction of an
approved category of staff, and if the below staff are not the approved category,
* a physician
* a licensed/ “waivered” psychologist
* a licensed/ “associate” social worker
* a licensed/ registered/marriage and family therapist or
* a registered nurse
• In addition,
* client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client’s participation
in and agreement with the plan. Examples of the documentation include, but are not limited to,
reference to the client’s participation and agreement in the body of the plan, client signature on
the plan, or a description of the client’s participation and agreement in progress notes.
* client signature on the plan will be used as the means by which the CONTRACTOR(S)
documents the participation of the client
* when the client’s signature is required on the client plan and the client refuses or is unavailable
for signature, the client plan will include a written explanation of the refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the individual
elements of the client plan described in item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client’s progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• 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
Exhibit D
Page 3 of 3
0374 d dbh
2. Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
Mental Health Services
Medication Support Services
Crisis Intervention
Exhibit E
Page 1 of 2
0374 f dbh
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit E
Page 2 of 2
0374 f dbh
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights
EXHIBIT F
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
EXHIBIT F
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation,
the provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Health Care
Service’s day treatment requirements. The COUNTY shall review the provider’s written
program description for compliance with the State Department of Health Care Service’s
day treatment requirements.
12. The COUNTY may accept the host county’s site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example: conversion
from a non-profit status).
• The provider adds day treatment or medication support services when medications shall be
administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some physical plant
changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or
members of the community.
Exhibit G
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit G
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process – the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider’s claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit H
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit H
Page 2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit I
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit I
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5) Authorized Signature
Signature: Date:
Exhibit J
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
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
YES NO
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) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit J
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks