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COUNTY OF FRESNO
Fresno, CA
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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, EXODUS RECOVERY, INC., a for-profit California
corporation, whose business address is 9808 Venice Boulevard, Suite 700 Culver City, California
90232, hereinafter referred to as “CONTRACTOR,” collectively, “the parties.”
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a
qualified agency to operate its adult sixteen (16) bed acute inpatient psychiatric health facility (PHF) to
provide psychiatric services to adult clients who may be admitted on a voluntary basis or involuntary
basis and may include Medi-Cal beneficiaries, Medicare and Medicare/Medi-Cal beneficiaries,
indigent/uninsured clients, and jail inmates who are referred by the DBH, DBH contract providers,
hospital emergency rooms, other COUNTY departments and other agencies. In addition, Conservatees
of the COUNTY that are placed in other residential settings and attending court in Fresno County will
be temporarily placed at the PHF operated by CONTRACTOR until each such Conservatee’s court
proceeding is completed.
WHEREAS, COUNTY, through its 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 operate said PHF 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 Exhibit A, “Acute Inpatient Psychiatric Health Facility, Scope of Work,” attached hereto and by this
reference incorporated herein and made part of this Agreement.
B. CONRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 952-5344 dated May 14, 2015 and Addendum
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No. One (1) to COUNTY’s RFP No. 952-5344 dated June 10, 2015, hereinafter collectively referred to
as COUNTY’s Revised RFP, and CONTRACTOR’s response to said Revised RFP dated July 7, 2015
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 Revised RFP, 3) to the Response
to the Revised RFP. A copy of COUNTY’s RFP No. 952-5344 and CONTRACTOR’s response thereto
shall be retained and made available during the term of this Agreement by COUNTY’s DBH Contracts
Division.
C. It is acknowledged by all parties hereto that COUNTY's DBH Contracts Division
shall monitor the PHF operated by CONTRACTOR, in accordance with Section Fourteen (14) of this
Agreement.
D. CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
consisting of staff from COUNTY's DBH to discuss PHF requirements, data reporting, training,
policies and procedures, overall program operations and any problems or foreseeable problems that
may arise.
E. CONTRACTOR shall maintain requirements as a MHP organizational provider
throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement. If for
any reason, this status is not maintained, COUNTY may terminate this Agreement pursuant to Section
Three (3) of this Agreement.
F. CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, CONTRACTOR shall have staff hired and in place for program services
and operations or COUNTY may, in addition to other remedies it may have, suspend referrals or
terminate this Agreement, in accordance with Section Three (3) of this Agreement.
G. CONTRACTOR’s affiliate Exodus Foundation, Inc., a non-profit Internal
Revenue Code section 501 (c)(3) corporation, shall execute a mutually agreeable lease agreement with
COUNTY for the lease of COUNTY-owned property located at 4411 Kings Canyon Ave., Fresno, CA
93702 building 319 as the site for CONTRACTOR’s provision of PHF services under this Agreement.
If CONTRACTOR or CONTRACTOR’s affiliate fails to accomplish these tasks prior to providing
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services under this Agreement, COUNTY may, in addition to other remedies it may have, suspend
referrals or terminate this Agreement, in accordance with Section Three (3) of this Agreement.
H. It is acknowledged by all parties hereto that COUNTY’s DBH shall be
responsible for COUNTY DBH approved facility improvements to the PHF. Payments for COUNTY
DBH approved improvements to the PHF will be funded by the COUNTY’s DBH. Said improvements
to the PHF shall be at the discretion of the COUNTY’s DBH Director or designee. Improvements
stated herein shall mean those improvements to the PHF designed to assist with the operation of the
PHF. The parties agree that the anticipated start date for the CONTRACTOR’s PHF to commence
serving clients will be January 1, 2016 under this Agreement.
I. It is acknowledged by all parties hereto that landscaping, building maintenance,
and utilities for the PHF will be provided by COUNTY and COUNTY will invoice CONTRACTOR
for said services as further described in Section Five (5) of this Agreement.
2. TERM
This Agreement shall become effective on the 1st day of October, 2015 and shall
terminate on the 30th day of June, 2016.
Effective July 1, 2016, this Agreement, subject to satisfactory outcomes performance and
subject to State funding each year, shall continue for an additional three (3) year term with an option
for two (2) additional twelve (12) month periods upon the same terms and conditions herein set forth,
unless written notice of non-renewal is given by COUNTY, CONTRACTOR or COUNTY’s DBH
Director or designee, not later than sixty (60) days prior to the close of the then current Agreement
term.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving 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:
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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 upon the giving of sixty (60) days advance written notice
of an intention to terminate to CONTRACTOR.
4. COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with the budget set forth in Exhibit B, attached hereto and by this
reference incorporated herein and made part of this Agreement.
A. Maximum Contract Amount
The maximum amount under this Agreement for the initial term, (October 1, 2015
through June 30, 2016) shall not exceed Two Million Forty Eight Thousand Two Hundred Ninety Six
and No/100 Dollars ($2,048,296.00).
The maximum amount for the first period of automatic renewal (July 1, 2016 through
June 30, 2017) shall not exceed Three Million Six Hundred Ninety Eight Thousand Seven Hundred
Fifty Nine and No/100 Dollars ($3,698,759.00).
The maximum amount for the second period of automatic renewal (July 1, 2017 through
June 30, 2018) shall not exceed Three Million Eight Hundred Ten Thousand Eight Hundred Eighty Six
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and No/100 Dollars ($3,810,886.00).
The maximum amount for the third period of automatic renewal (July 1, 2018 through
June 30, 2019) shall not exceed Three Million Nine Hundred Twenty Six Thousand Two Hundred One
and No/100 Dollars ($3,926,201.00).
The maximum amount for the fourth period of renewal (July 1, 2019 through June 30,
2020) shall not exceed Four Million Forty Five Thousand Fifty Four and No/100 Dollars
($4,045,054.00).
The maximum amount for the fifth period of renewal (July 1, 2020 through June 30,
2021) shall not exceed Four Million One Hundred Sixty Seven Thousand Five Hundred Ninety Six and
No/100 Dollars ($4,167,596.00)
In no event shall the maximum contract amount for the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess of
Twenty One Million Six Hundred Ninety Six Thousand Seven Hundred Ninety Two and No/100
Dollars ($21,696,792.00) during the total five (5) year nine month (9) month term of this Agreement.
B. If CONTRACTOR fails to generate the Medi-Cal revenue amounts set forth in
Exhibit B, the COUNTY shall not be obligated to pay the difference between the estimated revenue and
the actual revenue generated.
It is further understood by COUNTY and CONTRACTOR that any Medi-Cal revenue
above the amounts stated herein will be used to directly offset the COUNTY’s contribution of funds
identified in Exhibit B. The offset of funds will also be clearly identified in monthly invoices received
from CONTRACTOR as further described in Section Five (5) of this Agreement.
Travel shall be reimbursed based on actual expenditures and mileage reimbursement shall
be at CONTRACTOR’s adopted rate per mile, not to exceed the Internal Revenue Service published
rate.
Payment shall be made upon certification or other proof satisfactory to COUNTY’s DBH
that services have actually been performed by CONTRACTOR as specified in this Agreement.
C. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply
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with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
D. Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval
by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be
made after receipt and verification of actual expenditures incurred by CONTRACTOR for monthly
program costs, as identified in Exhibit B, in the performance of this Agreement and shall be
documented to COUNTY on a monthly basis by the tenth (10th) of the month following the month of
said expenditures. The parties acknowledge that the CONTRACTOR will be performing hiring,
training, and credentialing of staff, configuring the facility and office space, and obtaining site
certification from the COUNTY Mental Health Plan (Mental Health Plan).
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a
detailed general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL
reports and supporting documentation shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance, as further described in Section Five (5) herein.
E. COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
All final invoices, including actual cost per unit, and/or any final budget modification
requests shall be submitted by CONTRACTOR within sixty (60) days following the final month of
service for which payment is claimed. No action shall be taken by COUNTY on invoices 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.
G. 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 payments to CONTRACTOR. The amount of the deferred
payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The
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period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s
delay of payment to COUNTY plus forty-five (45) days.
H. CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR’s deficiency discovered through the State audit
process and COUNTY utilization review during the course of this Agreement. At COUNTY’s
election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon
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
Mental Health Plan utilization review process or through the State Department of Health Care Services
(DHCS) cost report audit settlement process for Medi-Cal eligible clients.
I. It is understood by CONTRACTOR and COUNTY that this Agreement is funded
with mental health funds to serve individuals with SMI (Serious Mental Illness), many of whom have
co-occurring substance use disorders. It is further understood by CONTRACTOR and COUNTY that
funds shall be used to support appropriately integrated services for co-occurring substance use
disorders in the target population, and that integrated services can be documented in crisis assessments,
interventions, and progress notes documenting linkages.
5. INVOICING
A. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each
month for the prior month’s actual services rendered to DBHInvoices@co.fresno.ca.us. After
CONTRACTOR renders service to referred clients, CONTRACTOR shall invoice COUNTY for
payment, certify the expenditure, and submit electronic claiming data into COUNTY’s electronic
information system for all clients, including those eligible for Medi-Cal as well as those that are not
eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. COUNTY must pay
CONTRACTOR before submitting claims to DHCS for Federal and State reimbursement for Medi-
Cal eligible clients.
B. At the discretion of COUNTY’s DBH Director, or designee, if an invoice is
incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director, or designee,
shall have the right to withhold payment as to only that portion of the invoice that is incorrect or
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improper after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to
provide services for a period of ninety (90) days after notification of an incorrect or improper invoice.
If after the ninety (90) day period, the invoice(s) is still not corrected to COUNTY DBH’s satisfaction,
COUNTY’s DBH Director, or designee, may elect to terminate this Agreement, pursuant to the
termination provisions stated in Section Three (3) of this Agreement. In addition, for invoices
received ninety (90) days after the expiration of each term of this Agreement or termination of this
Agreement, at the discretion of COUNTY’s DBH Director, or designee, COUNTY’s DBH shall have
the right to deny payment of any additional invoices received.
C. Monthly invoices shall include a client roster, identifying volume reported by
payer group for clients served (including third party payer of services) by month and year-to-date.
D. CONTRACTOR shall submit monthly invoices and general ledgers that itemize
the line item charges for monthly program costs (per applicable budget, as identified in Exhibit B),
including the cost per unit calculation based on clients served within that month, and excluding
unallowable costs. Unallowable costs such as lobbying or political donations must be deducted from
the monthly invoice reimbursements. The invoices and general ledgers will serve as tracking tools to
determine if CONTRACTOR’s program costs are in accordance with its budgeted cost, and cost per
unit negotiated by service modes compared to actual cost per unit, as set forth in Exhibit B. The actual
cost per unit will be based upon total costs and total units of service. It will also serve for the
COUNTY to certify the public funds expended for purposes of claiming Federal and State
reimbursement for the cost of Medi-Cal services and activities. CONTRACTOR shall remit to
COUNTY on a quarterly basis, a summary report of total operational costs and volume of service unit
to report the actual costs per unit compared to the negotiated rate, as identified in Exhibit B, to report
interim cost per unit. The quarterly reports will be used by COUNTY to ensure compliance with
Federal and State reimbursements certified public expenditures.
E. CONTRACTOR will remit annually within ninety (90) days from June 30, a
schedule to provide the required information on published charges for all authorized direct specialty
mental health services. The published charge listing will serve as a source document to determine the
CONTRACTOR’s usual and customary charge prevalent in the public mental health sector that is used
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to bill the general public, insurers or other non-Medi-Cal third party payers during the course of
business operations.
F. CONTRACTOR shall submit monthly staffing reports that identify all direct
service and support staff, applicable licensure/certifications, and full time hours worked to be used as a
tracking tool to determine if CONTRACTOR’s program is staffed according to the services provided
under this Agreement.
G. CONTRACTOR must maintain such financial records for a period of seven (7)
years or until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be
responsible for any disallowances related to inadequate documentation.
H. CONTRACTOR is responsible for collection and managing data in a manner to
be determined by DHCS and the Mental Health Plan in accordance with applicable rules and
regulations. COUNTY’s electronic information system is a critical source of information for
purposes of monitoring service volume and obtaining reimbursement. CONTRACTOR must attend
COUNTY DBH’s Business Office training on equipment reporting for assets, intangible and sensitive
minor assets; COUNTY’s electronic information system; and related cost reporting.
I. CONTRACTOR shall submit service data into COUNTY’s electronic information
system within ten (10) calendar days from the date services were rendered. Federal and State
reimbursement for Medi-Cal specialty mental health services is based on public expenditures certified
by the CONTRACTOR. CONTRACTOR must submit a signed certified public expenditure report,
with each respective monthly invoice. DHCS expects the claims for Federal and State reimbursement
to equal the amount the COUNTY paid the CONTRACTOR for the service rendered less any funding
sources not eligible for Federal and State reimbursement.
J. 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 electronic information system; 2) providing an electronic file
compatible with COUNTY’s electronic information system; or 3) integration between COUNTY’s
electronic information system and CONTRACTOR’s information system(s).
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K. If a client has other health coverage (OHC) such as private insurance, or Federal
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
mailed, before the service can be entered into the COUNTY’s electronic information system. A
copy of explanation of benefits or CMS 1500 is required as documentation. CONTRACTOR must
report all revenue collected from OHC, third-party, client-pay or private-pay in each monthly
invoice and in the cost report that is required to be submitted. CONTRACTOR shall submit monthly
invoices for reimbursement that equal the amount due CONTRACTOR less any funding sources not
eligible for Federal and State reimbursement. CONTRACTOR must comply with all laws and
regulations governing the Federal 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 regulations and rules
promulgated by the Federal Centers for Medicare and Medicaid Services as they relate to
participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for
compliance as of the effective date of each Federal, State or local law or regulation specified.
L. Data entry shall be the responsibility of the CONTRACTOR. The direct specialty
mental health services data must be reconciled by the CONTRACTOR to the monthly invoices
submitted for payment. COUNTY shall monitor the volume of services and cost of services entered
into the COUNTY’s electronic information system. Any and all audit exceptions resulting from the
provision and reporting 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 electronic information system.
M. Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR will establish and maintain Medi-Cal certification or become
certified within ninety (90) days of the effective date of this Agreement through COUNTY to provide
reimbursable services to Medi-Cal eligible clients. In addition, CONTRACTOR shall work with the
COUNTY’s DBH to execute the process if not currently certified by COUNTY for credentialing of
staff. During this process, the CONTRACTOR will obtain a legal entity number established by the
DHCS, as this is a requirement for maintaining Mental Health Plan organizational provider status
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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 from the
COUNTY. CONTRACTOR will not be reimbursed by COUNTY for any services rendered prior to
certification.
CONTRACTOR shall provide specialty mental health services in accordance with the
COUNTY’s Mental Health Plan. CONTRACTOR must comply with the “Fresno County Mental
Health Plan Compliance Program and Code of Conduct” set forth in Exhibit C, attached hereto and
incorporated herein by reference and made part of this Agreement.
CONTRACTOR may provide direct specialty mental health services using unlicensed
staff as long as the individual is approved as a provider by the Mental Health Plan, is supervised by
licensed staff, works within his/her scope and only delivers allowable direct specialty mental health
services. It is understood that each service 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 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
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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
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, attached hereto as
Exhibit B, 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 DBH Director or designee
and CONTRACTOR. Said budget line item and service volume/types of service unit changes shall not
result in any change to the maximum compensation amount payable to CONTRACTOR, as stated
herein.
In addition, changes to the scope of services and responsibilities of the CONTRACTOR
may be made with the written approval of the COUNTY’s DBH Director, or his/her designee. Said
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.
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
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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.
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 Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Five Million
Dollars ($5,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire
legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a combined
single limit of One Million Dollars ($1,000,000). Coverage should include owned
and non-owned vehicles used in connection with this Agreement.
C. Real and Property Insurance
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 purchase and owned property, at a minimum, as
discussed in Section Twenty (21) of this Agreement.
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All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of
the COUNTY’S personal property in possession of CONTRACTOR and/or used
in the execution of this Agreement. COUNTY will be identified on an appropriate
certificate of insurance as the certificate holder and will be named as an
Additional Loss Payee on the Property Insurance Policy.
D. Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., 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.
E. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by 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, Department of Behavioral Health, 3133
N. Millbrook Ave, Fresno, California, 93703, Attention: Contracts Division, stating that such insurance
coverages 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
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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 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 each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff
shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary
for the provision of the services hereunder and required by the laws and regulations of the United States
of America, State of California, the County 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 Exhibit D, "Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part
of this Agreement. During site visits, COUNTY shall be allowed to review records of services
provided, including the goals and objectives of the treatment plan, and how the therapy provided is
achieving the goals and objectives.
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13. REPORTS
A. Outcome Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to change at
COUNTY’s DBH discretion.
B. Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
data, and other information as COUNTY’s DBH may request pertaining to matters covered by this
Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments
until there is compliance. In addition, CONTRACTOR shall provide written notification and
explanation to COUNTY within five (5) days of any funds received from another source to conduct the
same services covered by this Agreement.
C. Quarterly Progress Reports
CONTRACTOR shall complete Quarterly Progress Reports according to State
Department of Health Care Services (DHCS) regulations, in the form set forth in Exhibit E, attached
hereto and by this reference incorporated herein and made part of this Agreement. Quarterly reports
shall be submitted to COUNTY’s DBH Contracts Division for review within thirty (30) days of the end
of each quarter.
D. Daily Census Reports
CONTRACTOR will submit a copy of admitted clients on a daily basis to
COUNTY’s DBH Director and/or designee identifying clients by State DHCS client identification
number, Social Security number, Date of Birth, Age, length of stay, Axis I Diagnosis, housing status,
and financial status such as Medi-Cal and/or general relief, identify clients primary physician status,
and identify discharged clients in a format acceptable to COUNTY’S DBH Director or designee. Said
daily census reports shall accompany each monthly invoice submitted by CONTRACTOR.
E. Cost Report
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CONTRACTOR agrees to submit a complete and accurate detailed cost report to
the COUNTY’s DBH on an annual basis for each fiscal year ending June 30th in the format prescribed
by the State 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 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 clients. The CONTRACTOR will remit a schedule to provide the required
information on published charges for all authorized services. The report will serve as a source
document to determine the CONTRACTOR’s usual and customary charge prevalent in the public
mental health sector that is used to bill the general public, insurers or other non-Medi-Cal third party
payors 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 electronic information system.
Each fiscal year ending June 30, CONTRACTOR shall remit a hard copy of their
annual cost report with a signed cover letter and requested support documents to County of Fresno,
Attention: DBH Cost Report Team, PO BOX 45003, Fresno CA 93718. In addition, CONTRACTOR
shall remit an electronic copy or any inquiries to DBHcostreportteam@co.fresno.ca.us. COUNTY shall
provide instructions of the cost report, cost report training, State DHCS cost report template
worksheets, and deadlines to submit the cost reports as determined by the State each fiscal year.
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 lobbying or political donations must be deducted on the cost
report and monthly invoice reimbursements.
If the CONTRACTOR does not submit the cost report by the deadline, including
any extension period granted by the COUNTY, the COUNTY may withhold payments of pending
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invoicing under compensation until the cost report has been submitted and clears COUNTY desk audit
for completeness.
F. Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and
CONTRACTOR agree to settle dollar amounts disallowed or settled in accordance with DHCS audit
settlement findings related to the reimbursement provided under this Agreement. CONTRACTOR will
participate in the several phases of settlements between COUNTY/CONTRACTOR and DHCS. The
phases of initial cost reporting for settlement according to State reconciliation of records for paid Medi-
Cal services and audit settlement are: State DHCS audit 1) initial cost reporting - after an internal
review by COUNTY, the COUNTY files the 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 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 costs and/or units of services reported on the CONTRACTOR’s legal entity
cost report. COUNTY may choose to appeal and therefore reserves the right to defer payback
settlement with CONTRACTOR until resolution of the appeal. DHCS Audits will follow Federal
Medicaid procedures for managing overpayments. If at the end of the Audit Settlement, the COUNTY
determines that it overpaid the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-
Cal related overpayment back to the COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification
by the COUNTY, or COUNTY shall withhold future payments until all excess funds have been
recouped by means of an offset against any payments then or thereafter owing to CONTRACTOR
under this or any other Agreement between the COUNTY and CONTRACTOR.
14. MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
the State DHCS, or their designees, the right to review and monitor records, programs or procedures, at
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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 to all State requirements, including
those identified in Exhibit F “State Mental Health Requirements”, attached hereto and by this reference
incorporated herein and made part of this Agreement.
17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall be required to maintain Mental Health Plan organizational
provider certification by Fresno County. CONTRACTOR must meet Medi-Cal organizational
provider standards as listed in Exhibit G, Medi-Cal Organizational Provider Standards, attached hereto
and incorporated herein and made part of this Agreement. It is acknowledged that all references to
Organizational Provider and/or Provider in Exhibit G shall refer to CONTRACTOR. In addition,
CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health Plan as
described in Exhibit H, attached hereto and by this reference incorporated herein and made part of this
Agreement. CONTRACTOR shall also file an incident report for all incidents involving clients,
following the protocol and using the worksheet identified in Exhibit I, attached hereto and by this
reference incorporated herein and made part of this Agreement, or a protocol and worksheet presented
by CONTRACTOR that is acceptable by COUNTY’s DBH Director or designee.
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.
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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 (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security
of PHI pursuant to the Agreement in compliance with 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.
20. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
enter into a contractual relationship with the COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR by the COUNTY, including but not limited to the following:
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;
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3) Mobile device has the remote wipe feature enabled/ and
4) A secure connection is used.
B. CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief
Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on
non-COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer,
and/or designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive
data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY data
internally and externally.
F. Confidential client information transmitted to one party by the other by means
of electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
128 BIT or higher. Additionally, a password or pass phrase must be utilized.
G. CONTRACTOR is responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY’s confidential information,
data maintained in computer files, program documentation, data processing systems, data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
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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. PROPERTY OF COUNTY
A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified
items will be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1. Asset must have life span of over one year.
2. The asset is not a repair part
3. The asset must be valued at or greater than the capitalization thresholds for the asset type
Asset type Threshold
• land $0
• buildings and improvements $100,000
• infrastructure $100,000
• be tangible $5,000
o equipment
o vehicles
• or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
• and capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is approved and
identified as an asset it will be tagged with a COUNTY program number. A Fixed asset log will be
maintained by COUNTY’s Asset Management System and annual inventoried until the asset is fully
depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be inventoried
in comparison to COUNTY’s DBH Asset Inventory System.
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B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are
sensitive assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and
other sensitive items as determined by COUNTY’s DBH Director or designee. CONTRACTOR
maintains a tracking system on the items and are not required to be capitalized or depreciated. The
items are subject to annual inventory for compliance.
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate
in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration
of this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
unable to produce the assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1. To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2. To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used, in accordance with procedures developed by COUNTY.
All such lists shall be submitted to COUNTY within ten (10) days of any request therefore; and
3. To report in writing to COUNTY immediately after discovery, the lost or
theft of any items of equipment. For stolen items, the local law enforcement agency must be contacted
and a copy of the police report submitted to COUNTY.
D. The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of
this Agreement as appropriate, and must be directly related to CONTRACTOR’s services or activity
under the terms of this Agreement. COUNTY’s DBH may refuse reimbursement for any costs
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resulting from equipment purchased, which are incurred by CONTRACTOR, if prior written approval
has not been obtained from COUNTY.
E. CONTRACTOR must obtain prior written approval from COUNTY’s DBH
whenever there is any modification or change in the use of any property acquired or improved, in
whole or in part, using funds under this Agreement. If any real or personal property acquired or
improved with said funds identified herein is sold and/or is utilized by CONTRACTOR for a use
which does not qualify under this Agreement, CONTRACTOR shall reimburse COUNTY in an
amount equal to the current fair market value of the property, less any portion thereof attributable to
expenditures of funds not provided under this Agreement. These requirements shall continue in effect
for the life of the property. In the event this Agreement expires, or terminates, the requirements for
this Section shall remain in effect for activities or property funded with said funds, unless action is
taken by the State government to relieve COUNTY of these obligations
22. 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 gender, pursuant to all applicable State and Federal statutes and regulations.
23. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
and participation in federally funded programs through the provision of comprehensive and quality
bilingual services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP consumers, including, but not limited to,
assessing the cultural and linguistic needs of its consumers, training of staff on the policies and
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procedures, and monitoring its language assistance program. The CONTRACTOR’s procedures must
include ensuring compliance of any sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR’s services who have limited or no English language
proficiency, including services to persons who are deaf or blind. Interpreter and translation services
shall be provided as necessary to allow such participants meaningful access to the programs, services
and benefits provided by CONTRACTOR. Interpreter and translation services, including translation of
CONTRACTOR’s “vital documents” (those documents that contain information that is critical for
accessing CONTRACTOR’s services or are required by law) shall be provided to participants at no cost
to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners
who interpret or translate for a program participant, or who directly communicate with a program
participant in a language other than English, demonstrate proficiency in the participant's language and
can effectively communicate any specialized terms and concepts peculiar to CONTRACTOR’s services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR’s plan to
address all fifteen national cultural competency standards as set forth in the “National Standards on
Culturally and Linguistically Appropriate Services (CLAS)”
(http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf). COUNTY’s annual on-site review
of CONTRACTOR shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR’s plan must be
updated accordingly.”
24. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
(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 to the Secretary of the United States Department of Health and Human Services,
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or upon request to 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 to the Secretary of the United States
Department of Health and Human Services, or upon request to 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.
25. SINGLE AUDIT CLAUSE
A. If 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 report and management letter to COUNTY. The audit report 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
audit report shall be delivered to COUNTY’s DBH Business Office, 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’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
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CONTRACTOR.
B. A single audit report is not applicable if CONTRACTOR’s Federal contracts do
not exceed Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR’s
only funding is through Drug related 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 Business Office, for review no later than nine
(9) months after the close of the fiscal year in which the funds supplied through this Agreement are
expended. Failure to comply with this Act may result in COUNTY performing the necessary audit
tasks or contracting with a qualified accountant to perform said audit. All audit costs related to this
Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective action to
eliminate any material noncompliance or weakness found as a result of such audit. Audit work
performed by COUNTY under this paragraph shall be billed to the CONTRACTOR at COUNTY 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.
26. COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached hereto and
incorporated herein by reference and made part of this Agreement. Within thirty (30) days of entering
into this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR’s
employees, agents and subcontractors providing services under this Agreement certify in writing, that
he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and Ethics.
CONTRACTOR shall ensure that within thirty (30) days of hire, all new employees, agents and
subcontractors providing services under this Agreement shall certify in writing that he or she has
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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, California 93703.
CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon
COUNTY by the Federal Government as a result of CONTRACTOR’s violation of the terms of this
Agreement.
27. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it, nor any of its officers,
are not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs: that it, nor any of its officers, have not been convicted of a criminal offense
related to the provision of health care items or services; nor has it, or any of its officers, been reinstated
to participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment,
or ineligibility. If COUNTY learns, subsequent to entering into a contract, 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.
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A. If COUNTY has notice that CONTRACTOR, or its officers, has been charged
with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during
the term of any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the
accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution
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 participate in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility.
1. In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
hires or engages such potential employee or subcontractor, CONTRACTOR will ensure that said
employee or subcontractor does no work, either directly or indirectly relating to services provided to
COUNTY.
2. Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee 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, debarred,
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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 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.
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.
28. PUBLICITY PROHIBITION
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.,
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purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section One (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 DBH Director or 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).
29. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client
or a client’s family. CONTRACTOR shall provide a copy of the detailed complaint log entries
concerning COUNTY -sponsored clients to COUNTY at monthly intervals by the tenth (l 0th) day of
the following month, in a format that is mutually agreed upon. In addition, CONTRACTOR shall
provide details and attach documentation of each complaint with the log. CONTRACTOR shall post
signs informing clients of their right to file a complaint or grievance. CONTRACTOR shall notify
COUNTY of all incidents reportable to State licensing bodies that affect COUNTY clients within
twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or
corrective action taken to resolve the complaint. In addition, CONTRACTOR shall inform every client
of their rights as set forth in Exhibit H.
30. 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
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herein and made part of this Agreement. 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.
31. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them,
their owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR”):
A. Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1. Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or
contract under a public transaction;
2. Violation of a federal or state antitrust statute;
3. Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4. False statements or receipt of stolen property.
B. Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR
from further business consideration. The information will be considered as part of the determination
of whether to continue and/or renew the Contract 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 contract awarded to
such CONTRACTOR may be immediately voided and terminated for material failure to comply
with the terms and conditions of the award.
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CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit K, attached
hereto and by this reference incorporated herein and made part of this Agreement. Additionally,
CONTRACTOR must immediately advise the COUNTY in writing if, during the term of this
Agreement: (1) CONTRACTOR becomes suspended, debarred, excluded or ineligible for
participation in federal or state funded programs or from receiving Federal funds as listed in the
excluded parties’ list system (http://www.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.
32. 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, attached hereto as Exhibit L
and incorporated herein by reference and made part of this Agreement, and submitting it to the
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
33. AUDITS AND INSPECTIONS
The 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 respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request
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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 (California Government Code section 8546.7).
34. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County Chief Executive Officer
Department of Behavioral Health Exodus Recovery, Inc.
3133 N. Millbrook Ave 9808 Venice Blvd, Suite 700
Fresno, CA 93702 Culver City, CA 90232
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.
35. GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
36. ENTIRE AGREEMENT
This Agreement, including all Exhibits, COUNTY’s Revised RFP No. 952-5344 and
CONTRACTOR’s Response 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 frrst hereinabove written.
3 ATTEST
4 CONTRACTOR
5 EXODUS RECOVERY, INC.
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B~~f
Print Name: L\J ~ r'VLut1.1Pii y
Title: PQ?SL PlE'l'·..rt
Chairman of Board, or President
Or any Vice President
Bxc--z~~ :/
Print NamJ 1?1?4.J ~CZ.Sif-csD
Secretary of Corporation, or
Any Assistant Secretary, or
Chief Financial Officer, or
Any Assistant Treasurer
Mailing Address:
9808 Venice Blvd, Suite 700
Culver City, CA 90232
Phone No. (310) 945-3350
Contact: Chief Executive Officer
COUNTY OF FRESNO
Chairman, Board of Superviso
BERNICE E. SEIDEL, Clerk
Board of Supervisors
A+-\-e..s-1-:
By ~S0.re, ~ sbo--p
~
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PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
COUNTY OF FRESNO
Fresno, CA
EXHIBIT A
Page 1 of 11
ACUTE INPATIENT PSYCHIATRIC HEALTH FACILITY (PHF)
SCOPE OF WORK
ORGANIZATION: Exodus Recovery, Inc.
ADDRESS: 9808 Venice Blvd Suite 700 Culver City, CA 90232
SITE ADDRESS: 4411 E Kings Canyon Rd Fresno, CA 93702 Bldg 319
SERVICES: Acute Inpatient Psychiatric Services
PROJECT DIRECTOR: Luana Murphy, President/CEO
PHONE NUMBER: (310) 945-3350
CONTRACT PERIOD: October 1, 2015 – June 30, 2016, (start up and implementation
period) followed by a three (3) year base contract and an option for two (2) twelve (12)
month renewals
CONTRACT AMOUNT: $2,048,296 October 1, 2015 through June 30, 2016
$3,698,759 FY 2016-17
$3,810,886 FY 2017-18
$3,926,201 FY 2018-19
$4,045,054 FY 2019-20
$4,167,596 FY 2020-21
I. SCHEDULE OF SERVICES:
CONTRACTOR shall operate the Psychiatric Health Facility (PHF) 24 hours per
day, seven (7) days per week.
II. TARGET POPULATION:
The target population will include male and female clients, who are 18 years and
older, who may be admitted on a voluntary or involuntary basis. These clients will
include Medi-Cal beneficiaries; Medicare and Medicare/Medi-Cal beneficiaries;
indigent/uninsured clients’ and jail inmates who are referred by the Department of
Behavioral Health (DBH), a contract provider with the DBH, hospital emergency rooms
(aka emergency departments), other County departments and other agencies to the
PHF. Jail inmates brought to the PHF will continue to be transported and supervised by
the Sheriff’s correctional staff.
In addition, Conservatees of the County that are placed in other residential settings and
attending court in Fresno County will be temporarily placed at the PHF operated by
CONTRACTOR until each such Conservatee’s court proceeding is completed.
EXHIBIT A
Page 2 of 11
CONTRACTOR shall work with the DBH Client Placement Team to execute placement
of County Conservatees that are being discharged from the PHF operated by the
CONTRACTOR.
Medical clearance in keeping with community standards of care will be required for
referred clients where there are indicators of an acute medical condition as determined
by a medical screening. However, in the event a referred client is known to possess a
contagious medical condition, said client shall be medically cleared by a local hospital
prior to admission to the PHF operated by CONTRACTOR.
CONTRACTOR shall accept direct admissions to the PHF from COUNTY DBH
programs or its contracted providers when PHF beds are available. Said direct admits
shall have medical clearance in keeping with community standards.
III. CONTRACTOR’S RESPONSIBILITIES:
CONTRACTOR shall provide the following:
1. Management of clients’ acute psychiatric disorders and prepare clients to
successfully use a less restrictive level of care.
2. A clinical program which has appropriate professional staffing on a 24 hours/7 days
a week basis.
3. In general, client admissions are executed any time during operating hours (24
hours a day/7 days a week) when there are PHF beds available. Discharges are
generally executed before 9:00pm each day of the week.
4. Provide a safe, secure environment for clients that encourage wellness and
recovery.
5. Provides for a comprehensive multi-disciplinary evaluation and treatment plan.
6. Provides dietary services.
7. Admission procedures for clients, who may be admitted on a voluntary or involuntary
basis. Individuals who are on involuntary holds in accordance with Welfare and
Institutions Code 5150 may be referred from hospital emergency rooms or by local
law enforcement agencies or by licensed medical/mental health professionals
certified by the County as 5150 Initial Evaluators.
8. Treatment Planning - CONTRACTOR shall provide the following services:
EXHIBIT A
Page 3 of 11
a. Mental Status Examination
b. Medical Evaluation
c. Psycho-Social Assessment
d. Nursing Assessment
e. Multi-Disciplinary Milieu Treatment Program
f. Individualized Focused Treatment Planning
g. Aftercare planning including care coordination with current and/or identified
post discharge providers including sharing of records.
h. Appropriate prescriptions to clients at discharge as well as make any other
necessary arrangements to ensure the client’s well-being.
9. Provide an intensive treatment program which has individualized treatment plans.
10. Stabilize clients as soon as possible in order to assist them in their recovery from
mental illness.
11. Effectively partner with other programs in accepting County clients for admission for
acute inpatient psychiatric services and also to work collaboratively in discharge
planning to insure appropriate ongoing outpatient specialty mental health treatment
services are provided.
12. Identify County clients with frequent admissions during the fiscal year and develop
strategies with other County and community agencies to reduce readmissions.
13. Effectively interact with community agencies, other mental health programs and
providers, natural support systems and families to assist clients to be discharged to
the most appropriate level of care.
14. Work effectively with the legal system to provide temporary conservatorship if
necessary and appropriate for clients who require additional inpatient care.
15. Ancillary Services – CONTRACTOR shall provide the following:
a. Provide services to clients who are designated to be incompetent to stand
trial in order to allow clients to stand trial.
b. CONTRACTOR’s psychiatrist staff shall provide court testimony, written
reports, and documentation relevant to the PHF clients when required.
16. Comply with the requirements of the Fresno County Mental Health Plan (FCMHP)
and must complete and submit a Treatment Authorization Request (TAR) and the
EXHIBIT A
Page 4 of 11
supporting documentation for all Medi-Cal, Medi-cal/Medicare, and UMDAP
admissions to the FCMHP. The FCMHP will perform a utilization review of all
admissions to determine that the documentation demonstrates that medical
necessity criteria as defined by the California Department of Health Care Services
(DHCS) was met for each day of the hospitalization, except for the day of discharge.
17. Enter all client service information, admission data and billing information into the
County’s electronic information system and will be responsible for any and all audit
exceptions pertaining to the delivery of services. The CONTRACTOR will also be
responsible for the mandated reporting of patient information and
admission/discharge data and other required reports to the Office of State Health
Planning and Development (OSHPD), the California DHCS, and meet the
submission deadlines each calendar year.
18. Staffing
CONTRACTOR shall provide the appropriate type and level of staffing to provide for
a clinically effective program design.
a. The staffing pattern for the PHF shall meet all State licensing and
regulatory requirements including medical staff standards, nursing staff
standards, social work and rehabilitation staff requirements pursuant to Title
22, Division 5, Chapter 9, Article 3, Section 77061 of the California Code of
Regulations for PHF’s. There shall be an appropriate level of supervisory staff
as required by regulation or statute. All staff, which requires State licensure or
certification, will be required to be licensed or certified in the State of
California and be in good standing with the State licensing or certification
board.
b. All facility staff, who provide direct client care or perform coding/billing
functions, must meet the requirements of the FCMHP Compliance Program.
This includes the screening for excluded persons and entities by accessing or
querying the applicable licensing board(s), the National Practitioner Data
Bank (NPDB), Office of Inspector General's List of Excluded
Individuals/Entities (LEIE), Excluded Parties List System (EPLS) and Medi-
Cal Suspended and Ineligible List prior to hire and monthly thereafter. In
addition, all licensed/registered/waivered staff must complete a FCMHP
Provider Application and be credentialed by the FCMHP’s Credentialing
Committee. All licensed staff shall have Department of Justice (DOJ), Federal
Bureau of Investigation (FBI), and Sheriff fingerprinting (Lives can) executed.
EXHIBIT A
Page 5 of 11
c. Peer and/or family support staff will be utilized on the treatment team to
provide Peer/Family specific services to enhance the services provided by
professional staff.
d. Organized Clinical Staff - The organized clinical staff of CONTRACTOR shall
be composed of all licensed mental health professionals as included in Title
22, Division 5, Chapter 9, Article 4, Section 77083 (Organized Clinical Staff)
of the California Code of Regulations.
e. Organized Medical Staff - CONTRACTOR shall meet the requirement for an
organized medical staff pursuant to Title 22, Division 5, Chapter 9, Article 3,
Section 77061 (Staffing) of the California Code of Regulations.
19. Medical Records and Mandated Reporting to the Office of State Health Planning and
Development
a. The CONTRACTOR shall develop and implement a medical record system
which meets all State and Federal requirement and clearly documents
medical necessity for both treatment and billing services. Medical records
shall be kept in such a manner as to comply with the Fresno County Quality
Improvement standards and Federal and State quality standards. Fresno
County has an electronic medical record system and the expectation is that
the CONTRACTOR will participate in this record keeping system.
b. CONTRACTOR will be responsible for accommodating appropriate and legal
“release of information” requests for the facility and shall adhere to applicable
Federal and State regulations in providing protected health information per
such requests.
c. CONTRACTOR will be required to provide mandated reporting of client
information and admission/discharge data to the OSHPD and meet the
submission deadlines on June 30 and December 31 each calendar year.
20. Pharmaceutical Services- CONTRACTOR must provide for the level of
pharmaceutical services as a PHF pursuant to Title 22, Section 5, Chapter 9, Article
3, 77079.13 of the California Code of Regulations. If CONTRACTOR intends to
utilize any type of automated dispensing system, the cost of that system and
pharmacy consultants shall be included as part of the CONTRACTOR’s budget.
21. Physical Health Care - CONTRACTOR shall provide admission history and physical
examination, will order and receive ancillary health exams which are considered
community standards of care, provide dietary services and maintain a written
agreement for medical services with one or more general acute care hospitals.
EXHIBIT A
Page 6 of 11
22. Schedule of Active Therapies - CONTRACTOR shall provide active therapies that
will be provided as part of the clinical treatment program. The schedule shall include
group therapies, skill development and client education activities, wellness and
recovery focused treatment, family therapy, scheduled community meetings,
recreational and exercise programs. The treatment team is expected to schedule
client’s participation activities tailored to each client’s individual needs.
23. CONTRACTOR shall provide a safe and secure environment to provide for clinical
and medical assessment, diagnostic formulation, crisis intervention, medication
management and clinical treatment for mental health clients with an acute
psychiatric disorder. CONTRACTOR shall utilize cost containment strategies for the
provision of stock and prescription medications to clients (i.e. use of prescription
assistance program, contracting with a pharmaceutical benefits management
company, etc.).
24. CONTRACTOR shall use the Department’s current medication formulary for
consistency purposes in the event that clients are discharged from the PHF and
potentially linked to other outpatient programs within the Department. In addition, the
CONTRACTOR shall execute a contract with a pharmaceutical benefit management
(PBM) company or pharmacy. The CONTRACTOR will not use, or be a part of, the
Department’s current agreement for PBM services. The injectables currently utilized
are Haldol and Prolixin.
25. CONTRACTOR shall integrate mental health and substance abuse services through
comprehensive continuous integrated systems of care for the life span of those
served and to work as partners with a shared vision: to create a coordinated and
comprehensive system of service delivery. CONTRACTOR shall develop a formal
written Continuous Quality Improvement (CQI) action plan to identify measurable
objectives toward the achievement of Co-Occurring Disorders (COD) capability that
will be addressed by the program during the contract period. These objectives
should be achievable and realistic for the program, based on the self-assessment
and the program priorities, but need to include attention to making progress on the
following issues, at minimum:
a. Welcoming policies, practices, and procedures related to the engagement of
individuals with co-occurring issues and disorders;
b. Removal or reduction of access barriers to admission based on co-occurring
diagnosis or medication;
c. Improvement in routine integrated screening, and identification in the
County’s electronic information system of how many clients served have co-
occurring issues;
EXHIBIT A
Page 7 of 11
d. Developing the goal of basic co-occurring competency for all treatment staff,
regardless of licensure or certification, and
e. Documentation of coordination of care with collaborative mental health and/or
substance abuse providers for each client.
IV. CULTURAL AND LINGUISTIC COMPETENCE REQUIREMENTS:
CONTRACTOR shall:
1. Ensure compliance with Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section
2000d, and 45 C.F.R. Part 80) and Executive Order 12250 of 1979 which prohibits
recipients of Federal financial assistance from discriminating against persons based
on race, color, national origin, sex, disability or religion. This is interpreted to mean
that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive
and quality bilingual services.
2. Create and maintain policies and procedures for ensuring access and appropriate
use of trained interpreters and material translation services for all LEP consumers,
including, but not limited to, assessing the cultural and linguistic needs of its clients,
training of staff on the policies and procedures, and monitoring its language
assistance program. The CONTRACTOR's procedures must include ensuring
compliance of any sub-contracted providers with these requirements.
3. Ensure that minors shall not be used as interpreters.
4. Conduct and submit to County an annual cultural and linguistic needs assessment to
promote the provision and utilization of appropriate services for its diverse client
population. The needs assessment report shall include findings and a plan outlining
the proposed services to be improved or implemented as a result of the assessment
findings, with special attention to addressing cultural and linguistic barriers and
reducing racial, ethnic, language, abilities, gender, and age disparities.
5. Develop internal systems to meet the cultural and linguistic needs of the
CONTRACTOR's client census including the incorporation of cultural competency in
the CONTRACTOR's mission; establishing and maintaining a process to evaluate
and determine the need for special - administrative, clinical, welcoming, billing, etc. -
initiatives related to cultural competency.
6. Develop recruitment and retention initiatives to establish contracted program staffing
that is reflective and responsive to the needs of the program and target population.
EXHIBIT A
Page 8 of 11
7. Establish designated staff person to coordinate and facilitate the integration of
cultural competency guidelines and attend the Fresno County Department of
Behavioral Health Cultural Competency Committee monthly meetings. The
designated person will provide an array of communication tools to distribute
information to staff relating to cultural competency issues.
8. Keep abreast of evidence-based and best practices in cultural competency in mental
health care and treatment to ensure that the CONTRACTOR maintains current
information and an external perspective in its policies. The CONTRACTOR shall
evaluate the effectiveness of strategies and programs in improving the health status
of cultural-defined populations.
9. Ensure that an assessment of a client’s sexual orientation is included in the bio-
psychosocial intake process. CONTRACTOR's staff shall assume that the
population served may not be in heterosexual relationships. Gender sensitivity and
sexual orientation must be covered in annual training.
10. Utilize existing community supports, referrals to transgender support groups, etc.,
when appropriate.
11. Report its efforts to evaluate cultural and linguistic activities as part of the
CONTRACTOR's ongoing quality improvement efforts in the monthly activities
report. Reported information may include clients’ complaints and grievances, results
from client satisfaction surveys, and utilization and other clinical data that may reveal
health disparities as a result of cultural and linguistic barriers.
V. TRAINING REQUIREMENTS:
CONTRACTOR shall:
1. Attend annual Cultural Competence training.
2. Attend annual Compliance, Billing and Documentation training.
3. Attend County’s 5150 certification training.
4. Attend other required trainings provided by the County.
VI. PROGRAM OUTCOMES:
The Department of Behavioral Health is dedicated to supporting the wellness of
individuals, families and communities in Fresno County who are affected by, or at risk
of, mental illness and/or substance use disorders through cultivation of strengths toward
EXHIBIT A
Page 9 of 11
promoting recovery in the least restrictive environment (note - the 1st five (5) items listed
below will be utilized to support this DBH Mission). The following items listed below
represent program goals to be achieved by CONTRACTOR in addition to
CONTRACTOR-developed outcomes. The program’s success will be based on the
number of goals it can achieve, resulting from performance outcomes. The
CONTRACTOR will utilize computerize tracking system with which outcome measure
and other relevant client data, such as demographics, will be maintained.
1. Behavioral Health Integrated Access – The time between client arrival and
admission to the PHF, until assessment.
2. Wellness, Recovery and Resiliency Supports – program, services or philosophical
approaches which support the concept of wellness, recovery and resiliency in our
clients. Client levels of care, peer support, family advocacy, education and
employment, housing
3. Cultural/Community Defined Practices – programs, services or philosophical
practices which support the unique cultural specific needs of individuals receiving
care. Suggested penetration rate for particular groups can possibly be used to
measure.
4. Behavioral Health Clinical Care – programs, services where direct therapeutic
treatment is provided. Included in the frame work of ‘Levels’ of care where a client’s
needs, as identified through assessment/screening, are matched with a complexity
and intensity of services to meet those needs. Recovery 360 – Levels of Care and
fidelity of the program are examples.
5. Infrastructure Supports –includes all personnel, equipment, program and facilities
which exist to support the delivery of care to the clients we serve. Includes safety,
quality and regulatory compliance functions, along with outcome
assessments/program evaluation, training and technology. i.e., cost effectiveness of
services, Staff Training and development, Quality Improvement, Program evaluation,
regularity compliance efforts, personnel recruitment.
6. Effectiveness of discharge planning as demonstrated by the referral and linkage to
the Department of Behavioral Health programs, community providers and other
community resources.
7. Collaborative approach and treatment strategies to reduce readmission of clients
with frequent readmissions to the facility.
8. Denial rate for PHF days that do not meet Medi-Cal medical necessity criteria as
determined by the utilization review performed by the Fresno County Mental Health
Plan.
9. Initial Screening- Percent of patients discharged that were screened by the 3rd day
post admission for all of the following: risk of violence to self, risk of violence to
others, substance use, psychological trauma history, and patient strengths.
EXHIBIT A
Page 10 of 11
10. Hours of Physical Restraint Use - Total hours all patients spent in physical restraint
as a proportion of total inpatient hours. Restraint is defined as mechanical and
manual devises that restrict freedom of movement of the body.
11. Hours of Seclusion Use - Total hours all patients spent in seclusion as a proportion
of total inpatient hours. Seclusion is defined as restricted alone to a room or area
where the patient is not allowed to leave without the permission of staff.
12. Discharge on Multiple Antipsychotic Medications - Percent of patients discharged on
two or more antipsychotic medications as a proportion of patients discharged on one
or more antipsychotic medications. Antipsychotic medications include regularly
scheduled oral doses and long-acting injectable forms, regardless of diagnosis.
13. Discharge on Multiple Antipsychotic Medications with Appropriate Justification.
Percent of patients discharged on multiple antipsychotic medications with
appropriate justification as a proportion of patients discharged on two or more
antipsychotic medications. Appropriate justifications are limited to augmentation of
clozapine, tapering to monotherapy, and history of at least three failed trials of
monotherapy.
14. Continuing Care Plan Created - Percent of patients discharged with a continuing
care plan created that includes all of the following: reason for hospitalization,
discharge diagnosis, discharge medications, and next level of care
recommendations. Minimum information for all discharge medications includes
medication name, dose, and indications for use.
15. Continuing Care Plan Transmitted. Percent of patients discharged with a complete
continuing care plan (defined in #14) that is transmitted to next level of care provider
by the 5th day post discharge.
16. CONTRACTOR shall also propose their own outcomes measures that are deemed
to best evaluate the success of the clients and program.
17. COUNTY DBH may adjust the outcome measurements needed under this program
periodically, so as to best measure the success of clients and program as
determined by COUNTY.
VII. COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Perform a utilization review (through its FCMHP) of all Medi-Cal, Medi-Cal/Medicare,
and UMDAP admissions, to determine that the documentation demonstrates that
medical necessity criteria as defined by the California Department of Health Care
Services (DHCS) was met for each day of the hospitalization, except for the day of
discharge.
2. Provide oversight (through the County Department of Behavioral Health (DBH), or
designee) of the CONTRACTOR'S PHF program. In addition to contract monitoring
EXHIBIT A
Page 11 of 11
of program(s), oversight includes, but not limited to, coordination with the State
Department of Health Care Services in regard to program administration and
outcomes.
3. Assist the CONTRACTOR in making linkages with the total mental health system.
This will be accomplished through regularly scheduled meetings as well as formal
and informal consultation
4. Participate in evaluating the progress of the overall program and the efficiency of
collaboration with the vendor staff and will be available to the contractor for ongoing
consultation.
5. Receive and analyze statistical data outcome information from CONTRACTOR
throughout the term of contract on a monthly basis. DBH will notify the vendor when
additional participation is required. The performance outcome measurement process
will not be limited to survey instruments but will also include, as appropriate, client
and staff interviews, chart reviews, and other methods of obtaining required
information.
6. Recognize that cultural competence is a goal toward which professionals, agencies,
and systems should strive. Becoming culturally competent is a developmental
process and incorporates at all levels the importance of culture, the assessment of
cross-cultural relations, vigilance towards the dynamics that result from cultural
differences, the expansion of cultural knowledge, and the adaptation of services to
meet culturally-unique needs. Offering those services in a manner that fails to
achieve its intended result due to cultural and linguistic barriers is not cost effective.
To assist the CONTRACTOR'S efforts towards cultural and linguistic competency,
DBH shall provide the following at no cost to vendor(s):
a. Technical assistance to CONTRACTOR regarding cultural competency
requirements and sexual orientation training.
b. Technical assistance for CONTRACTOR in translating behavioral health and
substance abuse services information into DBH's threshold languages
(Spanish, Laotian, Cambodian and Hmong). Translation services and costs
associated will be the responsibility of the vendor.
(security, and janitorial costs at bidders cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director 1.00 $30,000 $30,000
0002 Title Program Support 1.00 $12,480 $12,480
0003 Title Administrator 0.10 $3,575 $3,575
SALARY TOTAL 2.10 $46,055 $0 $46,055
PAYROLL TAXES:
0030 OASDI $414 $0 $414
0031 FICA/MEDICARE $3,523 $0 $3,523
0032 U.I.$500 $0 $500
PAYROLL TAX TOTAL $4,437 $0 $4,437
EMPLOYEE BENEFITS:
0040 Retirement 1842 $0 $1,842
0041 Workers Compensation 2722 $0 $2,722
0042 $4,606 $0 $4,606
EMPLOYEE BENEFITS TOTAL $9,170 $0 $9,170
SALARY & BENEFITS GRAND TOTAL $59,662
OPERATING EXPENSES:
1060 $0
1061 $0
1062 $0
1063 $0
1064 $0
1065 $0
1066 Office Supplies & Equipment $0
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $0
1070 Program Supplies - Medical $0
1071 $0
1072 $0
1073 $0
1074 $46,000
1075 $0
1076 Other - One Time Costs $62,642
1077 Other - One Time Costs Contingency $0
OPERATING EXPENSES TOTAL $108,642
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Other - Administrative Overhead $30,609
FINANCIAL SERVICES TOTAL $30,609
TOTAL PROGRAM EXPENSES $198,913
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Orientation/Recruitment
Staff Mileage/vehicle maintenance
Transportation of Clients
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Start-Up/Implementation Budget - October 1, 2015 through June 30, 2016 (9 months)
Publications
Budget Categories -Total Proposed Budget
Line Item Description (Must be itemized)
Telephone
Health Insurance (medical vision, life, dental)
Answering Service
EXHIBIT B
Page 1 of 20
(security, and janitorial costs at bidders cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director (RN)1.00 $59,998 $59,998
0002 Title Rehab Specialist Coord (OT/RT)1.00 $4,680 $42,120 $46,800
0003 Title Mental Health Workers 8.40 $139,776 $139,776
0004 Title LMFT/LCSW 1.00 $36,400 $36,400
0005 Title Peer Advocate/Counselor 1.00 $12,480 $12,480
0006 Title Data Specialist 1.00 $17,680 $17,680
0007 Title Program Support 1.00 $24,960 $24,960
0008 Title Administrator 0.10 $7,150 $7,150
0009 Title (MD/NP/Nursing found on Line 1097)$0
SALARY TOTAL 14.50 $114,468 $230,776 $345,244
PAYROLL TAXES:
0030 OASDI $1,030 $2,077 $3,107
0031 FICA/MEDICARE $8,757 $17,654 $26,411
0032 U.I.$1,144 $2,307 $3,451
PAYROLL TAX TOTAL $10,931 $22,038 $32,969
EMPLOYEE BENEFITS:
0040 Retirement $4,579.00 $9,231 $13,810
0041 Workers Compensation $6,765.00 $13,639 $20,404
0042 $11,447 $23,078 $34,525
EMPLOYEE BENEFITS TOTAL $22,791 $45,948 $68,739
SALARY & BENEFITS GRAND TOTAL $446,952
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $8,250
1012 Utilities $62,365
1013 Janitorial $42,663
1014 Maintenance (facility)$5,331
1015 Security $47,500
1016 Maintenance (durable medical equipment)$0
1017 Other $0
1018 Other $0
FACILITY/EQUIPMENT TOTAL $166,109
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Start-Up/Implementation Budget- October 1, 2015 through June 30, 2016 (9 months)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Health Insurance (medical vision, life, dental)
EXHIBIT B
Page 2 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Start-Up/Implementation Budget- October 1, 2015 through June 30, 2016 (9 months)
OPERATING EXPENSES:
1060 $30,000
1061 $0
1062 $1,500
1063 $1,250
1064 $0
1065 $1,000
1066 Office Supplies & Equipment $10,000
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $3,000
1070 Program Supplies - Medical $15,000
1071 $6,000
1072 $1,250
1073 $350
1074 $17,500
1075 $0
1076 Other - License/Business Tax $750
1077 Other - Recovery 360 Training $1,750
OPERATING EXPENSES TOTAL $89,350
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $7,500
1081 External Audit $2,500
1082 Liability Insurance $5,000
1083 Other - Administrative Overhead $241,224
FINANCIAL SERVICES TOTAL $256,224
Answering Service
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
Publications
Telephone
EXHIBIT B
Page 3 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Start-Up/Implementation Budget- October 1, 2015 through June 30, 2016 (9 months)
SPECIAL EXPENSES (Consultant/Etc.):
1087 Consultant (network & data management)$15,000
1088 Translation Services $900
1089 Medication Supports $32,500
1090 Food Service $84,000
1091 Laundry service $16,200
1092 Medical Waste Disposal $1,250
1093 Nutritionist Services $0
1094 X-ray and EKG services $2,700
1095 Pharmaceutical Consultant $0
1096 Medical Services $0
1097 Other - Contracted Services $728,598
1098 Other - Registry $9,600
SPECIAL EXPENSES TOTAL $890,748
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures $0
2002 Other $0
2003 Other $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $1,849,383
DIRECT SERVICE REVENUE:
Vol/Units
of Svc Rate $ Amt.
3000
Mental Health Services
(Individual/Family/Group Therapy)$0
3100 Case Management $0
3200 Crisis Services $0
3300 Medication Support $0
3400 Psychiatric Health Facility Services 2,926 $632.00 $1,849,383
3500 other $0
DIRECT SERVICE REVENUE TOTAL 2,926 $1,849,383
$1,387,038
Cost Per Unit $632.00
Funding Streams Reimbursement Population Served Percentage
4000 Private Insurance -
4100 Uninsured 25%462,346
4200 Medi-Cal FFP 75%693,519
4300 Behavioral Health Realignment 693,519
OTHER REVENUE TOTAL $1,849,383
TOTAL PROGRAM REVENUE $1,849,383
Medi-cal Revenue
EXHIBIT B
Page 4 of 20
(security, and janitorial costs at bidder cost)
Item Price Qty Amount Notes
Telepsych Equipment $12,000.00 2 $12,000.00 Connection to other Exodus sites
Phone System Upgrade $12,000.00 1 $12,000.00 Module to add PHF phones into existing system
Medical Supplies $3,000.00 1 $3,000.00 Drug testing supplies, syringes, medicine cups
Stock Medications $3,000.00 1 $3,000.00 Initial stock medication supply
Network/Security Equipment $4,500.00 1 $4,500.00 Connection to other Exodus sites
Cabling $8,000.00 1 $8,000.00 Fiber cabling due to distance from program to phone closet in Bldg and Phone System
Computers $3,357.00 6 $20,142.00 Replacement of old desktops, including peripherals/softward
TOTAL $62,642.00
ONE TIME COSTS
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
One Time Costs - Details
EXHIBIT B
Page 5 of 20
(security, and janitorial costs at bidder cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director (RN)1.00 $119,995 $119,995
0002 Title Rehab Specialist Coord (OT/RT) 1.00 $9,360 $84,240 $93,600
0003 Title Mental Health Workers 8.40 $279,552 $279,552
0004 Title LMFT/LCSW 1.00 $72,800 $72,800
0005 Title Peer Advocate/Counselor 1.00 $24,960 $24,960
0006 Title Data Specialist 1.00 $35,360 $35,360
0007 Title Program Support 1.00 $49,920 $49,920
0008 Title Administrator 0.10 $14,300 $14,300
0009 Title (MD/NP/Nursing found on Line 1097)$0
SALARY TOTAL 14.50 $228,935 $461,552 $690,487
PAYROLL TAXES:
0030 OASDI $2,060 $4,154 $6,214
0031 FICA/MEDICARE $17,514 $35,309 $52,823
0032 U.I.$2,288 $4,614 $6,902
PAYROLL TAX TOTAL $21,862 $44,077 $65,939
EMPLOYEE BENEFITS:
0040 Retirement $9,157.00 $18,462 $27,619
0041 Workers Compensation $13,530.00 $27,278 $40,808
0042 $22,894 $46,155 $69,049
EMPLOYEE BENEFITS TOTAL $45,581 $91,895 $137,476
SALARY & BENEFITS GRAND TOTAL $893,902
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $16,500
1012 Utilities $124,729
1013 Janitorial $85,325
1014 Maintenance (facility)$10,661
1015 Security $95,000
1016 Maintenance (durable medical equipment)$0
1017 Other $0
1018 Other $0
FACILITY/EQUIPMENT TOTAL $332,215
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2016 through June 30, 2017 (12 months)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Health Insurance (medical vision, life, dental)
EXHIBIT B
Page 6 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2016 through June 30, 2017 (12 months)
OPERATING EXPENSES:
1060 $60,000
1061 $0
1062 $3,000
1063 $2,500
1064 $0
1065 $2,000
1066 Office Supplies & Equipment $20,000
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $6,000
1070 Program Supplies - Medical $30,000
1071 $12,000
1072 $2,500
1073 $700
1074 $35,000
1075 $0
1076 Other - License/Business Tax $1,500
1077 Other - Recovery 360 Training $3,500
OPERATING EXPENSES TOTAL $178,700
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $15,000
1081 External Audit $5,000
1082 Liability Insurance $10,000
1083 Other - Administrative Overhead $482,447
FINANCIAL SERVICES TOTAL $512,447
Publications
Telephone
Answering Service
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
EXHIBIT B
Page 7 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2016 through June 30, 2017 (12 months)
SPECIAL EXPENSES (Consultant/Etc.):
1087 Consultant (network & data management)$30,000
1088 Translation Services $1,800
1089 Medication Supports $65,000
1090 Food Service $168,000
1091 Laundry service $32,400
1092 Medical Waste Disposal $2,500
1093 Nutritionist Services $0
1094 X-ray and EKG services $5,400
1095 Pharmaceutical Consultant $0
1096 Medical Services $0
1097 Other - Contracted Services $1,457,195
1098 Other - Registry $19,200
SPECIAL EXPENSES TOTAL $1,781,495
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures $0
2002 Other $0
2003 Other $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $3,698,759
DIRECT SERVICE REVENUE:
Vol/Units
of Svc Rate $ Amt.
3000
Mental Health Services
(Individual/Family/Group Therapy)$0
3100 Case Management $0
3200 Crisis Services $0
3300 Medication Support $0
3400 Psychiatric Health Facility Services 5,843 $633.00 $3,698,759
3500 other $0
DIRECT SERVICE REVENUE TOTAL 5,843 $3,698,759
$2,774,069
Cost Per Unit $633.00
Funding Streams Reimbursement Population Served Percentage
4000 Private Insurance -
4100 Uninsured 25%924,690
4200 Medi-Cal FFP 75%1,387,035
4300 Behavioral Health Realignment 1,387,035
OTHER REVENUE TOTAL $3,698,759
TOTAL PROGRAM REVENUE $3,698,759
Medi-cal Revenue
EXHIBIT B
Page 8 of 20
(security, and janitorial costs at Bidder cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director (RN)$122,995 $122,995
0002 Title Rehab Specialist Coord (OT/RT)$9,594 $86,346 $95,940
0003 Title Mental Health Workers $286,541 $286,541
0004 Title LMFT/LCSW $74,620 $74,620
0005 Title Peer Advocate/Counselor $25,584 $25,584
0006 Title Data Specialist $36,244 $36,244
0007 Title Program Support $51,168 $51,168
0008 Title Administrator $14,658 $14,658
0009 Title (MD/NP/Nursing found on Line 1097)$0
SALARY TOTAL 0.00 $234,659 $473,091 $707,750
PAYROLL TAXES:
0030 OASDI $2,182 $4,400 $6,582
0031 FICA/MEDICARE $18,491 $37,280 $55,771
0032 U.I.$2,426 $4,892 $7,318
PAYROLL TAX TOTAL $23,099 $46,572 $69,671
EMPLOYEE BENEFITS:
0040 Retirement $9,386.00 $18,924 $28,310
0041 Workers Compensation $14,291.00 $28,811 $43,102
0042 $24,170 $48,728 $72,898
EMPLOYEE BENEFITS TOTAL $47,847 $96,463 $144,310
SALARY & BENEFITS GRAND TOTAL $921,731
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $16,995
1012 Utilities $128,471
1013 Janitorial $87,885
1014 Maintenance (facility)$10,981
1015 Security $97,850
1016 Maintenance (durable medical equipment)$0
1017 Other $0
1018 Other $0
FACILITY/EQUIPMENT TOTAL $342,182
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2017 through June 30, 2018 (12 months)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Health Insurance (medical vision, life, dental)
EXHIBIT B
Page 9 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2017 through June 30, 2018 (12 months)
OPERATING EXPENSES:
1060 $61,800
1061 $0
1062 $3,090
1063 $2,575
1064 $0
1065 $2,060
1066 Office Supplies & Equipment $20,600
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $6,180
1070 Program Supplies - Medical $30,900
1071 $12,360
1072 $2,575
1073 $721
1074 $36,050
1075 $0
1076 Other - License/Business Tax $1,545
1077 Other - Recovery 360 Training $3,605
OPERATING EXPENSES TOTAL $184,061
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $15,450
1081 External Audit $5,150
1082 Liability Insurance $10,300
1083 Other - Administrative Overhead $497,072
FINANCIAL SERVICES TOTAL $527,972
Publications
Telephone
Answering Service
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
EXHIBIT B
Page 10 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2017 through June 30, 2018 (12 months)
SPECIAL EXPENSES (Consultant/Etc.):
1087 Consultant (network & data management)$30,900
1088 Translation Services $1,854
1089 Medication Supports $66,950
1090 Food Service $173,040
1091 Laundry service $33,372
1092 Medical Waste Disposal $2,575
1093 Nutritionist Services $0
1094 X-ray and EKG services $5,562
1095 Pharmaceutical Consultant $0
1096 Medical Services $0
1097 Other - Contracted Services $1,500,911
1098 Other - Registry $19,776
SPECIAL EXPENSES TOTAL $1,834,940
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures $0
2002 Other $0
2003 Other $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $3,810,886
DIRECT SERVICE REVENUE:
Vol/Units
of Svc Rate $ Amt.
3000
Mental Health Services
(Individual/Family/Group Therapy)$0
3100 Case Management $0
3200 Crisis Services $0
3300 Medication Support $0
3400 Psychiatric Health Facility Services 5,836 $653.00 $3,810,886
3500 other $0
DIRECT SERVICE REVENUE TOTAL 5,836 $3,810,886
$2,858,164
Cost Per Unit $653.00
Funding Streams Reimbursement Population Served Percentage
4000 Private Insurance -
4100 Uninsured 25%952,721
4200 Medi-Cal FFP 75%1,429,082
4300 Behavioral Health Realignment 1,429,082
OTHER REVENUE TOTAL $3,810,886
TOTAL PROGRAM REVENUE $3,810,886
Medi-cal Revenue
EXHIBIT B
Page 11 of 20
(security, and janitorial costs at bidder cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director (RN)1.00 $126,070 $126,070
0002 Title Rehab Specialist Coord (OT/RT)1.00 $9,834 $88,505 $98,339
0003 Title Mental Health Workers 8.40 $293,704 $293,704
0004 Title LMFT/LCSW 1.00 $76,486 $76,486
0005 Title Peer Advocate/Counselor 1.00 $26,224 $26,224
0006 Title Data Specialist 1.00 $37,150 $37,150
0007 Title Program Support 1.00 $52,447 $52,447
0008 Title Administrator 0.10 $15,024 $15,024
0009 Title (MD/NP/Nursing found on Line 1097)$0
SALARY TOTAL 14.50 $240,525 $484,919 $725,444
PAYROLL TAXES:
0030 OASDI $2,304 $4,646 $6,950
0031 FICA/MEDICARE $19,531 $39,375 $58,906
0032 U.I.$2,500 $5,041 $7,541
PAYROLL TAX TOTAL $24,335 $49,062 $73,397
EMPLOYEE BENEFITS:
0040 Retirement $9,621.00 $19,397 $29,018
0041 Workers Compensation $15,081.00 $30,404 $45,485
0042 $25,496 $51,401 $76,897
EMPLOYEE BENEFITS TOTAL $50,198 $101,202 $151,400
SALARY & BENEFITS GRAND TOTAL $950,241
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $17,505
1012 Utilities $132,325
1013 Janitorial $90,522
1014 Maintenance (facility)$11,310
1015 Security $100,786
1016 Maintenance (durable medical equipment)$0
1017 Other $0
1018 Other $0
FACILITY/EQUIPMENT TOTAL $352,448
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2018 through June 30, 2019 (12 months)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Health Insurance (medical vision, life, dental)
EXHIBIT B
Page 12 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2018 through June 30, 2019 (12 months)
OPERATING EXPENSES:
1060 $63,654
1061 $0
1062 $3,183
1063 $2,652
1064 $0
1065 $2,122
1066 Office Supplies & Equipment $21,218
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $6,365
1070 Program Supplies - Medical $31,827
1071 $12,731
1072 $2,652
1073 $743
1074 $37,132
1075 $0
1076 Other - License/Business Tax $1,591
1077 Other - Recovery 360 Training $3,713
OPERATING EXPENSES TOTAL $189,583
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $15,914
1081 External Audit $5,305
1082 Liability Insurance $10,609
1083 Other - Administrative Overhead $512,113
FINANCIAL SERVICES TOTAL $543,941
Answering Service
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
Publications
Telephone
EXHIBIT B
Page 13 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2018 through June 30, 2019 (12 months)
SPECIAL EXPENSES (Consultant/Etc.):
1087 Consultant (network & data management)$31,827
1088 Translation Services $1,910
1089 Medication Supports $68,959
1090 Food Service $178,231
1091 Laundry service $34,373
1092 Medical Waste Disposal $2,652
1093 Nutritionist Services $0
1094 X-ray and EKG services $5,729
1095 Pharmaceutical Consultant $0
1096 Medical Services $0
1097 Other - Contracted Services $1,545,938
1098 Other - Registry $20,369
SPECIAL EXPENSES TOTAL $1,889,988
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures $0
2002 Other $0
2003 Other $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $3,926,201
DIRECT SERVICE REVENUE:
Vol/Units
of Svc Rate $ Amt.
3000
Mental Health Services
(Individual/Family/Group Therapy)$0
3100 Case Management $0
3200 Crisis Services $0
3300 Medication Support $0
3400 Psychiatric Health Facility Services 5,843 $672.00 $3,926,201
3500 other $0
DIRECT SERVICE REVENUE TOTAL 5,843 $3,926,201
$2,944,651
Cost Per Unit $672.00
Funding Streams Reimbursement Population Served Percentage
4000 Private Insurance -
4100 Uninsured 25%981,550
4200 Medi-Cal FFP 75%1,472,325
4300 Behavioral Health Realignment 1,472,325
OTHER REVENUE TOTAL $3,926,201
TOTAL PROGRAM REVENUE $3,926,201
Medi-cal Revenue
EXHIBIT B
Page 14 of 20
(security, and janitorial costs at bidder cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director (RN)1.00 $129,221 $129,221
0002 Title Rehab Specialist Coord (OT/RT)1.00 $10,080 $90,717 $100,797
0003 Title Mental Health Workers 8.40 $301,047 $301,047
0004 Title LMFT/LCSW 1.00 $78,398 $78,398
0005 Title Peer Advocate/Counselor 1.00 $26,879 $26,879
0006 Title Data Specialist 1.00 $38,079 $38,079
0007 Title Program Support 1.00 $53,758 $53,758
0008 Title Administrator 0.10 $15,400 $15,400
0009 Title (MD/NP/Nursing found on Line 1097)$0
SALARY TOTAL 14.50 $246,538 $497,041 $743,579
PAYROLL TAXES:
0030 OASDI $2,433 $4,906 $7,339
0031 FICA/MEDICARE $20,611 $41,553 $62,163
0032 U.I.$2,574 $5,190 $7,765
PAYROLL TAX TOTAL $25,618 $51,649 $77,267
EMPLOYEE BENEFITS:
0040 Retirement 9862 $19,882 $29,744
0041 Workers Compensation 15926 $32,109 $48,035
0042 $26,873 $54,177 $81,050
EMPLOYEE BENEFITS TOTAL $52,661 $106,168 $158,829
SALARY & BENEFITS GRAND TOTAL $979,675
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $18,030
1012 Utilities $136,295
1013 Janitorial $93,238
1014 Maintenance (facility)$11,650
1015 Security $103,810
1016 Maintenance (durable medical equipment)$0
1017 Other $0
1018 Other $0
FACILITY/EQUIPMENT TOTAL $363,023
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2019 through June 30, 2020 (12 months)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Health Insurance (medical vision, life, dental)
EXHIBIT B
Page 15 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2019 through June 30, 2020 (12 months)
OPERATING EXPENSES:
1060 $65,564
1061 $0
1062 $3,278
1063 $2,732
1064 $0
1065 $2,185
1066 Office Supplies & Equipment $21,855
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $6,556
1070 Program Supplies - Medical $32,782
1071 $13,113
1072 $2,732
1073 $765
1074 $38,245
1075 $0
1076 Other - License/Business Tax $1,639
1077 Other - Recovery 360 Training $3,825
OPERATING EXPENSES TOTAL $195,271
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $16,391
1081 External Audit $5,464
1082 Liability Insurance $10,927
1083 Other - Administrative Overhead $527,616
FINANCIAL SERVICES TOTAL $560,398
Answering Service
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
Publications
Telephone
EXHIBIT B
Page 16 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2019 through June 30, 2020 (12 months)
SPECIAL EXPENSES (Consultant/Etc.):
1087 Consultant (network & data management)$32,782
1088 Translation Services $1,967
1089 Medication Supports $71,027
1090 Food Service $183,578
1091 Laundry service $35,404
1092 Medical Waste Disposal $2,732
1093 Nutritionist Services $0
1094 X-ray and EKG services $5,901
1095 Pharmaceutical Consultant $0
1096 Medical Services $0
1097 Other - Contracted Services $1,592,316
1098 Other - Registry $20,980
SPECIAL EXPENSES TOTAL $1,946,687
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures $0
2002 Other $0
2003 Other $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $4,045,054
DIRECT SERVICE REVENUE:
Vol/Units
of Svc Rate $ Amt.
3000
Mental Health Services
(Individual/Family/Group Therapy)$0
3100 Case Management $0
3200 Crisis Services $0
3300 Medication Support $0
3400 Psychiatric Health Facility Services 5,837 $693.00 $4,045,054
3500 other $0
DIRECT SERVICE REVENUE TOTAL 5,837 $4,045,054
$3,033,790
Cost Per Unit $693.00
Funding Streams Reimbursement Population Served Percentage
4000 Private Insurance -
4100 Uninsured 25%1,011,263
4200 Medi-Cal FFP 75%1,516,895
4300 Behavioral Health Realignment 1,516,895
OTHER REVENUE TOTAL $4,045,054
TOTAL PROGRAM REVENUE $4,045,054
Medi-cal Revenue
EXHIBIT B
Page 17 of 20
(security, and janitorial costs at bidder cost)
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Title Program Director (RN)1.00 $132,452 $132,452
0002 Title Rehab Specialist Coord (RT/OT)1.00 $10,332 $92,985 $103,317
0003 Title Mental Health Workers 8.40 $308,573 $308,573
0004 Title LMFT/LCSW 1.00 $80,358 $80,358
0005 Title Peer Advocate/Counselor 1.00 $27,551 $27,551
0006 Title Data Specialist 1.00 $39,031 $39,031
0007 Title Program Support 1.00 $55,102 $55,102
0008 Title Administrator 0.10 $15,785 $15,785
0009 Title $0
SALARY TOTAL 14.50 $252,702 $509,467 $762,169
PAYROLL TAXES:
0030 OASDI $2,578 $5,197 $7,775
0031 FICA/MEDICARE $21,758 $43,865 $65,623
0032 U.I.$2,652 $5,346 $7,998
PAYROLL TAX TOTAL $26,988 $54,408 $81,396
EMPLOYEE BENEFITS:
0040 Retirement $10,108 $20,379 $30,487
0041 Workers Compensation $16,805 $33,880 $50,685
0042 $28,303 $57,060 $85,363
EMPLOYEE BENEFITS TOTAL $55,216 $111,319 $166,535
SALARY & BENEFITS GRAND TOTAL $1,010,100
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $0
1011 Rent/Lease Equipment $18,571
1012 Utilities $140,384
1013 Janitorial $96,035
1014 Maintenance (facility)$11,999
1015 Security $106,925
1016 Maintenance (durable medical equipment)$0
1017 Other $0
1018 Other $0
FACILITY/EQUIPMENT TOTAL $373,914
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2020 through June 30, 2021 (12 months)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Health Insurance (medical vision, life, dental)
EXHIBIT B
Page 18 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2020 through June 30, 2021 (12 months)
OPERATING EXPENSES:
1060 $67,531
1061 $0
1062 $3,377
1063 $2,814
1064 $0
1065 $2,251
1066 Office Supplies & Equipment $22,510
1067 $0
1068 Food $0
1069 Program Supplies - Therapeutic $6,753
1070 Program Supplies - Medical $33,765
1071 $13,506
1072 $2,814
1073 $788
1074 $39,393
1075 $0
1076 Other - License/Business Tax $1,688
1077 Other - Recovery 360 Training $3,939
OPERATING EXPENSES TOTAL $201,129
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $16,883
1081 External Audit $5,628
1082 Liability Insurance $11,255
1083 Other - Administrative Overhead $543,599
FINANCIAL SERVICES TOTAL $577,365
Publications
Telephone
Answering Service
Postage
Printing/Reproduction
Lodging
Legal Notices/Advertising
Household Supplies
Staff Travel (Out of County)
Staff Training/Registration
Staff Mileage/vehicle maintenance
Transportation of Clients
EXHIBIT B
Page 19 of 20
Acute Inpatient Psychiatric Services (16 bed PHF)
Exodus Recovery
Budget- July 1, 2020 through June 30, 2021 (12 months)
SPECIAL EXPENSES (Consultant/Etc.):
1087 Consultant (network & data management)$33,765
1088 Translation Services $2,026
1089 Medication Supports $73,158
1090 Food Service $189,085
1091 Laundry service $36,466
1092 Medical Waste Disposal $2,814
1093 Nutritionist Services $0
1094 X-ray and EKG services $6,078
1095 Pharmaceutical Consultant $0
1096 Medical Services $0
1097 Other - Contracted Services $1,640,086
1098 Other - Registry $21,610
SPECIAL EXPENSES TOTAL $2,005,088
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures $0
2002 Other $0
2003 Other $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $4,167,596
DIRECT SERVICE REVENUE:
Vol/Units
of Svc Rate $ Amt.
3000
Mental Health Services
(Individual/Family/Group Therapy)$0
3100 Case Management $0
3200 Crisis Services $0
3300 Medication Support $0
3400 Psychiatric Health Facility Services 5,837 $714.00 $4,167,596
3500 other $0
DIRECT SERVICE REVENUE TOTAL 5,837 $4,167,596
$3,125,697
Cost Per Unit $714.00
Funding Streams Reimbursement Population Served Percentage
4000 Private Insurance -
4100 Uninsured 25%1,041,899
4200 Medi-Cal FFP 75%1,562,848
4300 Behavioral Health Realignment 1,562,848
OTHER REVENUE TOTAL $4,167,596
TOTAL PROGRAM REVENUE $4,167,596
Medi-cal Revenue
EXHIBIT B
Page 20 of 20
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 1
PROGRAM OUTCOMES
Quarterly Progress Report
The following items listed below represent program goals to be achieved by contractor
in addition to contractor-developed outcomes. The program’s success will be based
on the number of goals it can achieve, resulting from performance outcomes. The
selected contractor will utilize a computerized tracking system with which outcome
measures and other relevant client data, such as demographics, will be maintained.
1. The time between client referral and admission to the PHF.
2. Effectiveness of discharge planning as demonstrated by the referral and linkage to
other Department of Behavioral Health programs, community providers and other
community resources.
3. Collaborative approach and treatment strategies to reduce readmission of clients
with frequent readmissions to the facility.
4. Denial rate for PHF that do not meet Medi-Cal medical necessity criteria as
determined by the utilization review performed by the Fresno County Mental Health
Plan.
Reporting Documents:
Annual, Quarterly, and monthly reports requested by the County, and utilized by
the Contractor to measure program goals/success are to be developed by the
Contractor and approved by the Department of Behavioral Health (DBH) Director
and/or designee.
Additional program outcomes developed by Contractor will be established and
approved by DBH prior to commencement of program operation. Some
additional outcomes Contractor may develop and seek approval are:
• Reduce incidence of involuntary hospitalization and incarcerations (Post
Discharge)
• Reduce frequency and severity of crisis in the community (Post Discharge)
• Increased acquisition of community living, coping and communication skills
• Reduction in high risk behavior (e.g. substance abuse, high risk sexual
activity)
• Increased linkage to and utilization of community resources and natural
supports to foster ongoing wellness and recovery – as defined by participant
• Discharge to a stable living situation
• Return to or linkage to outpatient mental health services
• Establishing a permanent relationship with one or more caring support person
Exhibit F
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 F
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 G
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 G
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 H
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 H
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 I
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
GGRRIIEEVVAANNCCEESS AANNDD IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
Exhibit I
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit J
Page 1 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
Exhibit K
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 K
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 L
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 L
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: