HomeMy WebLinkAbout32397Agreement No. 15-247
AGREEMENT 1
2 THIS AGREEMENT is made and entered into this 16th day of _ _,J,_,u~n=e __ , 2015, by and
3 between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
4 referred to as "COUNTY", and each PROVIDER listed in Exhibit A, "List of Providers", attached
5 hereto and by this reference incorporated herein, collectively hereinafter referred to as
6 PROVIDER(s)", and such additional PROVIDER(s) as may, from time to time during the term ofthis
7 Agreement, be added by COUNTY with the Department of Behavioral Health (DBH) Director, or
8 designee, approval. References in this Agreement to "party" or "parties" shall be understood to refer to
9 COUNTY and each PROVIDER, unless otherwise specified.
1 0 W I T N E S S E T H:
11 WHEREAS, COUNTY, through its DBH Managed Care program, is a Mental Health Plan as
12 defined in Title 9 ofthe California Code ofRegulations (C.C.R.), section 1810.226; and
13 WHEREAS, COUNTY, through its Mental Health Plan is in need ofPROVIDER(s) to provide
14 specialty mental health services to certain COUNTY's Medi-Cal beneficiaries, as specified in this
15 Agreement and as part of the Mental Health Plan, submitted to the California Department of Health
16 Care Services, pursuant to Article 5, section 14680-14685, Chapter 8.8, Division 9, Welfare and
1 7 Institutions Code, and originally approved by the COUNTY Board of Supervisors on March 17, 1998,
18 and again on May 16, 2006, and updated year-to-year; and
19 WHEREAS, PROVIDER(s) are qualified and willing to provide said services pursuant to the
2 0 terms and conditions of this Agreement; and
21 WHEREAS, it is to the mutual benefit of the parties hereto that an effective and economical
2 2 mental health managed care program be provided through a locally-administered program.
23 NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
2 4 hereto agree as follows:
1. SERVICES 25
26 A. PROVIDER(s) shall provide specialty mental health services as a "Provider",
2 7 specifically identified as either a "Group Provider" or ''Individual Provider":
28
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COUNTY OF FRESNO
Fresno, CA
"Provider"shall mean any mental health professional licensed in the State of
California as a psychiatrist,psychologist,clinical social worker,marriage and family therapist,or a
registered nurse with a Master's Degree,hereinafter referred to as "Provider",and contracting with
County to render certain covered services to Clients,pursuant to the terms and conditions of this
Agreement and as addressed in the "Fresno County Mental Health Plan Individual/Group Provider
Manual".
"Group Provider"is an organization that provides specialty mental health services
through two or more individual providers.Group provides include entities such as independent
practice associations, hospital outpatient departments,health care service plans and clinics.
"Individual Provider"is a licensed mental health professional whose scope of
practicepermits the practiceof psychotherapywithout supervision who provides specialtymental
health services directly to beneficiaries. Individual provider includes licensed physicians, licensed
psychologists,licensedclinical social workers, licensedmarriage, family and child counselors,and
registerednurses with a master's degree within their scopeof practice. Individualproviderdoes not
include licensed mental health professionals when they are acting as employees of an organizational
provideror PROVIDER(s)of organizational providers otherthanthe Mental Health Plan.
B.PROVIDER(s)shall provide specialty mental health services as listed in the
identified "Covered Services"listed below:
1."Covered Services"with requirements as identified in the current Fresno
County Mental HealthPlan Individual/Group Provider Manual (hereinafter "Provider Manual"),
together withany amendmentsor changesto the manual, and only when rendered by professionals
who meet the appropriate requirements to render Covered Services as described herein:
a.Rehabilitative services,including mental health services,medication
services,and crisis intervention.
b.Psychiatric inpatient hospital professional services.
c.Targeted case management.
d.Psychiatric services.
e.Psychologist services.
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f. Early and Periodic Screening Diagnosis and Treatment (EPSDT)
supplemental specialty mental health services.
g.Psychiatric nursing facility professional services.
2.These Covered Services are subject to the limitations set forth in the
statewide Medi-Cal Program,unless specifically exempted by the COUNTY.
3.Exempted services shall be only those services identified as excepted,
authorized in advance as exempted,and shall only apply to a specific and discreet time period and
number of authorized exempted services. Any one authorization to a PROVIDER(s)for exempted
services to a client shall not infer nor constitute subsequent or combined authorization for additional
exempted services to that client,or to any other client,nor to the PROVIDER(s),not to any other
PROVIDER(s).
4.Covered Services provided shall be subject to the limitations and
procedures listed in the Provider Manual,unless PROVIDER(s)is notified by COUNTY of a
modification to that policy.
5.PROVIDER(s)shall provide specialty mental health services only after
obtaining "Prior Authorization"from COUNTY,as identified below:
"Prior Authorization"-Prior authorization from the COUNTY shall be
required for all specialty mental health services with the exception of the initial assessment and crisis
intervention,pursuant to the terms and conditions of this Agreement,and as described in the Provider
Manual prior to the time services are rendered.Prior authorization shall be required for each, and each
subsequent,authorization period to include a specified number of contacts during such authorization
period.COUNTY shall not be obligated to compensate PROVIDER(s)for services rendered during a
non-authorized period,for services provided in excess of an authorized period,for services in excess
of the number of authorized contacts,or for services provided to ineligibles.No PROVIDER(s)shall
admit,treat,refer,or transfer a client without prior authorization and approval of COUNTY.
C.PROVIDER(s)shall provide specialty mental health services as a
Provider,and recognize the "Imposition of Additional Controls"as listed and the identified below:
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COUNTY OF FRESNO
Fresno,CA
"Imposition of Additional Controls"-PROVIDER(s)recognizes that the
COUNTY,through the utilization management and quality improvement process,may be required to
take action necessitating consultation with its Medical Director or with other physicians prior to
authorization of Covered Services or to terminate this Agreement.In the interest of program integrity
or the welfare of clients,COUNTY may introduce additional utilization controls as may be necessary
at any time and without advance notice to PROVIDER(s).In the event of such change,COUNTY
shall notify PROVIDER(s)in writing,and the change shall take effect upon the tenth (10th)calendar
day following the deposit of said notice,by COUNTY,in the United States mail,postage prepaid.
2.TERM
This Agreement shall be effective on the lsl day of July,2015,and terminate on the 30lh
day of June,2018.
Effective July lsl,2018,this Agreement,subject to satisfactory outcomes performance
and subject to available funding each year, shall be extended 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 or PROVIDER(s)or COUNTY'S DBH Director,or designee,not later than thirty
(30) days prior to the close of the 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 PROVIDER(s)sixty (60)days advance written notice.
B.Breach of Contract -COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
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any breach of this Agreement or any default which may then exist on the part of PROVIDER(s).
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default.COUNTY shall have the right to demand of PROVIDER(s)the repayment to
COUNTY of any funds disbursed to PROVIDER(s)under this Agreement,which in the judgment of
COUNTY were not expended in accordance with the terms of this Agreement.PROVIDER(s)shall
promptly refund any such funds upon demand or at COUNTY'S option, such repayment shall be
deducted from future payments owing to PROVIDER(s)under this Agreement.
C.Without Cause -Under circumstances other than those set forth above,this
Agreement may be terminated by PROVIDER(s)or COUNTY or COUNTY'S DBH Director, or
designee, upon the giving of sixty (60) days advance written notice of an intention to terminate. The
date of termination shall be set by consideration for the welfare of clients and necessary allowance for
notification to PROVIDER(s)and clients.
PROVIDER(s)may terminate with appropriate sixty (60) days advance written
notice of intent to terminate (with allowance for appropriate clinical transition of clients prior to
terminationof services) by PROVIDER(s)to COUNTYby Certified U.S. Mail,Return Receipt
Requested, addressed to the office of COUNTY as follows:
Director
County of Fresno
Department of Behavioral Health
4441 E.Kings Canyon
Fresno,CA 93702
4.COMPENSATION
A. COUNTY agrees to pay PROVIDER(s) and PROVIDER(s) agrees to receive
compensation at the reimbursement rates identified in ExhibitB,"IndividualandGroup Provider Fee
Schedule", attached hereto and incorporated herein by this reference.
COUNTY will reimburse PROVIDER(s)for Covered Services rendered to clients
only when all of the following conditions are met:
Conditions for Payment -
1.The client is eligible for Medi-Cal Program benefits at the time the
Covered Service is rendered by PROVIDER(s);
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2.The service is a Covered/Billable Service under the Mental Health Plan
according to the terms and conditions set forth in the Provider Manual in effect at that time;
3.Prior authorization was received by PROVIDER(s)from COUNTY;and
4. Claims for payment are submitted within thirty (30) days after the month
in which services were rendered, with the exception of claims subject to Section 5 of this Agreement.
For the period effective from July 1,2015 through June 30,2016,the maximum
compensation amount under this Agreement shall not exceed Three Million,Five Hundred Thousand,
and No/100 Dollars ($3,500,000.00)for all PROVIDER(s)combined.
For the period effective from July 1,2016 through June 30,2017,the maximum
compensation amount under this Agreement shall not exceed Three Million,Five Hundred Thousand,
and No/100 Dollars ($3,500,000.00)for all PROVIDER(s)combined.
For the period effective from July 1,2017 through June 30,2018,the maximum
compensation amount under this Agreement shall not exceed Three Million,Six Hundred Five
Thousand,and No/100 Dollars ($3,605,000.00)for all PROVIDER(s)combined.
For the period effective from July 1,2018 through June 30,2019,the maximum
compensation amount under this Agreement shall not exceed Three Million,Seven Hundred Thirteen
Thousand,One Hundred Fifty and No/100 Dollars ($3,713,150.00)for all PROVIDER(s)combined.
For the period effective from July 1,2019 through June 30,2020,the maximum
compensation amount under this Agreement shall not exceed Three Million,Eight Hundred Twenty-
Four Thousand,Five Hundred Forty-Five and No/100 Dollars ($3,824,545.00)for all PROVIDER(s)
combined.
For the entire term of this Agreement,the total maximum compensation amount
under this Agreement shall not exceed Eighteen Million,One Hundred Forty-Two Thousand,Six
Hundred Ninety-Five and No/100 Dollars ($18,142,695.00)for all PROVIDER(s)combined.
B.Payments shall be made upon certification or other proof satisfactory to
COUNTY'S DBH that services have actually been performed by PROVIDER(s)as specified in this
Agreement.
It is understood that all expenses incidental to PROVIDER(s)performance of
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services under this Agreement shall be borne by PROVIDER(s).If PROVIDER(s)fails to comply
with any provision of this Agreement,COUNTY shall be relieved of its obligation for further
compensation.
C.Payments shall be made by COUNTY to PROVIDER(s)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 5 herein. The parties acknowledge that
the PROVIDER(s)will be performing hiring,training,and credentialing of staff,configuring the
facility and office space,and obtaining site certification from the COUNTY'S DBH Mental Health
Plan.
E.COUNTY shall not be obligated to make any payments under this
Agreement if the request for payment is received by COUNTY more than sixty (60) days after this
Agreement has terminated or expired.
All final claims shall be submitted by PROVIDER(s)within sixty (60) days
following the final month of service for which payment is claimed. No action shall be taken by
COUNTY on claims submitted beyond the sixty (60) day closeout period. Any compensation which is
not expended by PROVIDER(s) pursuant to the terms and conditions of this Agreement shall
automatically revert to COUNTY.
F. The services provided by PROVIDER(s)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 PROVIDER(s).The amount of the deferred
paymentshall not exceed the amount of funding delayed by the State Controllerto COUNTY.The
periodof time of the deferral by COUNTYshall not exceed the periodof time of the State Controller's
delay of payment to COUNTY plus forty-five (45) days.
G.PROVIDER(s)shall be held financially liable for any and all future
disallowances/audit exceptions due to PROVIDER(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 PROVIDER(s).PROVIDER(s)shall
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not receivereimbursement for any units of services renderedthat are disallowedor denied bythe
Mental Health Plan utilization review process or through the California Department of Health Care
Services (DHCS) cost report audit settlement process as described in Section 15 of this Agreement for
Medi-Cal eligible clients.
5.PAYMENT AND CLAIMS PROCESSING
A.Condition for Payment -COUNTY will reimburse PROVIDER(s)for Covered
Services rendered to clients only when all of the following conditions are met:
1.The Client is eligible for Medi-Cal Program benefits at the time the Covered
Service is rendered by PROVIDER(s);
2.The service is Covered/Billable Service under the Mental Health Plan
according to the terms and conditions set forth in the Provider Manual in effect at that time;
3.Prior authorization was received by PROVIDER(s)from COUNTY;and
4.Claims for payment are submitted within thirty (30)days after the month in
which services were rendered,with the exception of claims subject to prior authorization have been
received by PROVIDER(s)from COUNTY.
B.Claims -PROVIDER(s)shall obtain and complete claim forms as adopted by the
COUNTY,as may be amended from time to time for use in the Mental Health Plan, for Covered
Services rendered to Clients,and shall submit completed claims to COUNTY within thirty (30) days
after the month in which services were rendered.For claims submitted for the payment of inpatient
care, fees shall be submitted within sixty (60) days after the month in which services were rendered.
Payment by COUNTY for PROVIDER(s)'services shall be in arrears within forty-five (45) days after
receipt and verification of PROVIDER(s)'claims by the COUNTY.Provider(s)certifies that with
each claim submitted that the Covered Services were provided solely by a Mental Health Services
PROVIDER.PROVIDER(s)further certifies with each claim submitted,that no active employee of
COUNTY has provided any service to any Clients on said claim,(Government Code §1090 and
Fresno County Charter §41).Should PROVIDER(s)fail to comply with any provision of this
Agreement,COUNTY shall be relieved of any obligation to compensate for services provided.
It is understood by all parties that all expenses incidental to PROVIDER(s)'performance of
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services under this Agreement shall be borne by PROVIDER(s).
It is understood that each claim is subject to audit for compliance with
Federal and State regulations and the Provider Manual,and that COUNTY may be making
payments on billings in advance of said review.In the event that a claim disapproved,
COUNTY may,at its sole discretion,withhold compensation or set off from other payments due
in the amount of said disapproved billings.This remedy is not exclusive and COUNTY may
seek requital from any other means,including but not limited to, a separate contract or
agreement with PROVIDER(s).
PROVIDER(s)shall submit claims at least monthly to:County of Fresno,
Department of Behavioral Health,Managed Care, P.O. Box 45003,Fresno,CA 93718-9886,
Attention:Provider Relations Specialist.Claims shall be submitted on the CMS 1500 insurance
form as outlined in the Provider Manual on a calendar month basis for all services provided to
Clients during the preceding month. Each claim shall be for one Client only and shall include
the name of individual Client,type of service,time and date of service,COUNTY billing code,
and duration of service.COUNTY shall have the right to deny payment for invoices not
submitted within thirty (30)days after the month in which services were rendered,with the
exception of claims submitted by PROVIDER(s)which received a prior authorization from
COUNTY.
COUNTY shall not make payment for services rendered to Clients which are,
in the opinion of COUNTY,determined to be not medically necessary or which have not been
authorized for reimbursement by COUNTY.PROVIDER(s)understands and agrees that
services are not Covered Services unless authorized in advance for reimbursement by COUNTY.
C.Claim Submission
Individual Providers shall submit hard copy claims to COUNTY as identified in
Section 5, herein. Group Providers may have the option of submitting hard copy claims as identified
herein, or to submit electronic billing for services directly through the COUNTY'S billing module,
AVATAR.For Group Providers that decide to enter electronic claiming data,PROVIDER(s)must
attend COUNTY'S Business Office training on the AVATAR claiming module.
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PROVIDER(s)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. For any Group Providers are entering data directly into AVATAR, the necessary data
can be provided by a variety of means, including, but not limited to: 1)direct data entry into
COUNTY'S information system;2)providing an electronic file compatible with COUNTY'S
information system; or 3)integration between COUNTY'S information system and the Group
Provider's information system.
Data entry shall be the responsibility of the Group Providers.The data for billing
must be reconciled by the Group Providers to the monthly claims submitted for payment.COUNTY
shall monitor the number and dollar amount of services entered into AVATAR.Group Providers shall
comply with all applicable policies, procedures, directives, and guidelines regarding the use of
COUNTY'S billing system.
D.Medi-Cal Certification and Mental Health Plan Compliance
1.Group Providers:
All Group Providers will establish and maintain Medi-Cal certification or
become certified within ninety (90) days of the effective date of this Agreement through the COUNTY
to providereimbursableservicesto Medi-Cal eligible adult clients. In addition, GroupProvidersshall
work with the COUNTY'S DBH Managed Care Division and DBH Business Office to execute the
processif not currentlycertified by COUNTYfor credentialingof staff. Duringthis process,the
GroupProviderswill obtain a legal entity number establishedby the DHCS, a requirementfor
maintaining organizational provider status throughout the term of this Agreement. Group Providers
will be requiredto become Medi-Calcertified prior to providingservices to Medi-Cal eligibleclients
and seekingreimbursementin COUNTY'Sbilling system. Group Providers will not be reimbursed by
COUNTY for any Medi-Cal services rendered prior to certification.
2.Individual and Group Providers:
Medi-Cal billing shall be in accordance with the Mental Health Plan.
PROVIDER(s) 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
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made part of this Agreement.
Medi-Cal can be billed for direct specialty mental health services of
unlicensed staff as long as the individual is approved as an organizational provider by the Mental
Health Plan, is supervised by licensed staff, works within his/her scope and only bills Medi-Cal for
allowable specialty mental health services.
It is understood that each claim is subject to audit for compliance with
Federal and State regulations,and that COUNTY may be making payments in advance of said review.
In the event that a Medi-Cal billable service is disapproved,COUNTY may, at its sole discretion,
withhold compensation or set off from other payments due the amount of said disapproved services.
PROVIDER(s)shall be responsible for audit exceptions to ineligible dates of services or incorrect
application of utilization review requirements.
6.INDEPENDENT CONTRACTORS
In performance of the work,duties,and obligations assumed by PROVIDER(s)under this
Agreement, it is mutually understood and agreed that PROVIDER(s),including any and all of
PROVIDER'(s)officers,agents, and employees will at all times be acting and performing as
independent contractor(s), 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 PROVIDER(s) shall
perform its work and function. However, COUNTY shall retain the right to administer this Agreement
so as to verify that PROVIDER(s)is performing their obligations in accordance with the terms and
conditions thereof.PROVIDER(s)and COUNTY shall comply with all applicable provisions of law
and the rules and regulations,if any,of governmental authorities having jurisdiction over matters
which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor(s),PROVIDER(s)shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
PROVIDER(s)shall be solely liable and responsible for providing to, or on behalf of, its employees all
legally-required employee benefits. In addition,PROVIDER(s)shall be solely responsible and save
COUNTY harmless from all matters relating to payment of PROVIDER'(s)employees,including
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compliance with Social Security,withholding,and all other regulations governing such matters. It is
acknowledged that during the term of this Agreement,PROVIDER(s)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.
Additions to Exhibit A,"List of Providers",may be made with written approval of
COUNTY'S DBH Director,or designee,as defined further in Section 8 of this Agreement.Changes to
the rates/types of service identified in Exhibit B,"Individual and Group Provider Fee Schedule", as
established by the Mental Health Plan, may be made with written approval of COUNTY'S DBH
Director, or designee. Said rate/types of service changes shall not result in any change to the
maximum compensation amount payable to PROVIDER(s), as stated herein. PROVIDER(s) will be
notified of any rate changes thirty (30) days prior to the effective date of the rate change.
8.ADDITIONS/DELETIONS OF PROVIDER(s)
COUNTY'S DBH Director, or designee, reserves the right at any time during the term of
this Agreement toadd PROVIDER(s)to Exhibit A,"Listof Providers".Itis understood any such
additions will not affect compensation paid to the other PROVIDER(s) under this Agreement. These
same provisions shallapplyto thedeletionof any PROVIDER(s)containedin Exhibit A,exceptthat
deletionsshall be made by mutual writtenconsent between COUNTYand the specific PROVIDER(s)
to be deleted or shall be in accordance with Section 5 of this Agreement.
Additions to Exhibit A, "List of Providers", may be made with written approval of
COUNTY'S DBH Director, or designee, upon COUNTY'S DBH Director, or designee, having
received and approved submitted proposals for additional PROVIDER(s).Proposals forthe inclusion
of PROVIDER(s)must be preparedand submittedto: Countyof Fresno, Departmentof Behavioral
Health, Managed Care,P.O.Box 45003,Fresno,CA 93718-9886.,Attention:Provider Relations
Specialist.
9.ADDITIONS/DELETIONS OF INDIVIDUAL PROVIDERS BY GROUP
PROVIDER
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As it relates to Group PROVIDER(s)who hire or subcontract the performance of
services under this Agreement,Group PROVIDER(s)shall notify COUNTY within ten (10)days of
any change in staff or subcontractors providing services to COUNTY clients,on behalf of the Group
PROVIDER.Individual PROVIDER(s),new to a Group,must be credentialed and approved by
COUNTY before being permitted to provide services to COUNTY clients.
10.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY and PROVIDER(s).
11.HOLD-HARMLESS
PROVIDER(s)agrees to indemnify,save, hold harmless,and at COUNTY'S request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by PROVIDER(s), its officers,
agentsor employees underthis Agreement,and from any and all costs and expenses, including
attorneyfeesand court costs, damages, liabilities,claims and lossesoccurring or resultingto any
person,firm or corporation who may be injured or damaged bythe performance,or failure to perform,
of PROVIDER(s),their officers,agents or employees under this Agreement.
PROVIDER(s) agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of PROVIDER(s).
12.INSURANCE
Without limiting COUNTY'S right to obtain indemnification from PROVIDER(s) or any
third parties,PROVIDER(s),at its sole expense, shall maintain in full forceand effect the following
insurance policies throughout the term of this Agreement:
A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million
Dollars ($2,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations, product
liability,contractual liability,Explosion, Collapse,and Underground(XCU),fire
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legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000)per person,Five
Hundred Thousand Dollars ($500,000)per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000),or such coverage with a combined
single limit of One Million Dollars ($1,000,000).Coverage should include owned
and non-owned vehicles used in connection with this Agreement.
C.Personal Property
PROVIDER(s)shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
loss payee. The personal property coverage shall be in an amount that will cover
the total of the COUNTY purchased and owned property,at a minimum,as
discussed in Section 19 of this Agreement.
D. All Risk Property Insurance
PROVIDER(s) will provide property coverage for the full replacement value of
the COUNTY'S Personal Property in the possession of PROVIDER(s)and/or
used in the execution of this Agreement.COUNTY will be identified on an
appropriatecertificateof insuranceas the certificate holderand will be namedas
an Additional Loss Payee on the Property Insurance Policy.
E.Fire Insurance and Extended Coverage
PROVIDER(s)shall add COUNTY as an additional Loss Payee thereon.
F.Professional Liability
If PROVIDER(s)employs licensed professional staff (e.g. Ph.D., R.N., L.C.S.W.,
L.M.F.T.) in providing services, Professional Liability Insurance with limits of
not less than One Million Dollars ($1,000,000)per occurrence,Three Million
Dollars ($3,000,000)annual aggregate.PROVIDER(s)agrees that it shall
maintain, at its sole expense, in full force and effect for a period of three (3) years
following the termination of this Agreement, one or more policies of professional
liability insurance with limits of coverage as specified herein.
G.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
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F.Child Abuse/Molestation and Social Services Coverage
PROVIDER(s)shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability.The
policy limits for these policies shall be $1,000,000 per occurrence with
$2,000,000 annual aggregate.The policies are to be on a per occurrence basis.
PROVIDER(s)shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
additional insured,but only insofar as the operations under this Agreement are concerned.Such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents and employees shall be excess only and not
contributingwith insuranceprovided under PROVIDER'(s) policiesherein. This insuranceshall 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 PROVIDER(s)signs this Agreement,
PROVIDER(s)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,CA 93703,Attention:Mental Health Contracted Services,stating
that such insurance coverages have been obtained and are in full force; that the County of Fresno, its
officers,agentsand employeeswill not be responsiblefor any premiums on the policies;that such
Commercial General Liability insurance names the County of Fresno, its officers, agents and
employees, individually and collectively, as additional insured, but only insofar as the operations
under this Agreement are concerned; that such coverage for additional insured shall apply as primary
insurance and any other insurance,or self-insurance,maintainedby COUNTY, its officers,agentsand
employees,shall beexcess only and not contributingwith insurance provided under PROVIDER'(s)
policies herein;andthatthis insurance shall notbe cancelled or changed without a minimum of thirty
(30) days advance,written notice given to COUNTY.
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In the event PROVIDER(s)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.
13.LICENSES/CERTIFICATES
Throughouteach term of this Agreement,PROVIDER(s)and PROVIDER'(s) staff shall
maintainall necessarylicenses,permits, approvals,certificates,waivers and exemptionsnecessaryfor
the provision of the services hereunder andrequiredbythe lawsand regulations of the United States of
America, State of California, the County of Fresno, and any other applicable governmental agencies.
PROVIDER(s)shall notify COUNTY immediatelyin writing of its inabilityto obtain or maintainsuch
licenses,permits,approvals,certificates,waivers and exemptions irrespective ofthe pendency of any
appeal related thereto.Additionally,PROVIDER(s)and PROVIDER'(s)staff shall comply with all
applicable laws,rulesor regulations,as maynowexistor be hereafter changed.
14.RECORDS
PROVIDER(s)shall maintain records in accordancewith Exhibit D,"Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part
ofthis Agreement.During site visits,COUNTY shall be allowed to review records of services
provided,including the goals and objectives ofthe treatment plan,and how the therapy provided is
achieving the goals and objectives.
15.REPORTS
A. Cost Report- PROVIDER(s)agrees to submit a complete and accuratedetailed
cost report on an annual basis for each fiscal year ending June 30th in the format prescribed by the
DHCS forthe purposes of Short Doyle Medi-Cal reimbursements andtotalcostsfor programs.Each
cost report will bethe source document for several phases of settlement withthe DHCS forthe
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purposes of Short Doyle Medi-Cal reimbursement. PROVIDER(s) shall report costs under their
approved legal entity number established during the Medi-Cal certification process. The information
provided applies to PROVIDER(s)for program related costs for services rendered to Medi-Cal and
non Medi-Cal. The PROVIDER(s)will remit a schedule to provide the required information on
published charges (PC) for all authorized services.The report will serve as a source document to
determine their usual and customary charge prevalent in the public mental health sector that is used to
bill the general public,insurers or other non-Medi-Cal third party payers during the course of business
operations.PROVIDER(s)must report all collections for Medi-Cal/Medicare services and collections.
PROVIDER(s)shall also submit with each cost report a copy of the PROVIDER'(s)general ledger
that supports revenues and expenditures for the said services.PROVIDER(s)must also include a
reconciled detailed report of the total units of services rendered under this Agreement compared to the
units of services entered by PROVIDER(s)into COUNTY'S data system.
Cost reports must be submitted to the COUNTY as a hard copy with a signed
cover letter and electronic copy of the completed DHCS cost report form along with requested support
documents following each fiscal year ending June 30th.During the month of September of each year
this Agreement is effective, COUNTY will issue instructions of the annual cost report which indicates
the training session, DHCS cost report template worksheets, and deadlines to submit as determined by
the State annually. Remit the hard copies of the cost reports to County of Fresno, Attention: Cost
Report Team, P.O. Box 45003, Fresno, CA 93718.Remit the electronic copy or any inquiries to
DBHcostreportteam@co.fresno.ca.us.
All cost reports must be prepared in accordance with Generally Accepted
Accounting Principles (GAAP)and Welfare and Institutions Code §§5651(a)(4),5664(a), 5705(b)(3)
and 5718(c).Unallowable costs such as lobby or political donations must be deducted on the cost
report and invoice reimbursements.
If the PROVIDER(s)does not submit the cost report by the deadline,including
any extension period granted by the COUNTY, the COUNTY may withhold payments of pending
invoicing under compensation until the cost report has been submitted and clears COUNTY desk audit
for completeness.
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B.Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter,COUNTY and PROVIDER(s)
agree to settle dollar amounts disallowed or settled in accordance with DHCS and COUNTY audit
settlement findings related to the Medi-Cal and realignment reimbursements.PROVIDER(s)will
participate in the several phases of settlements between COUNTY,PROVIDER(s)and DHCS. The
phases of initial cost reporting for settlement according to State reconciliation of records for paid
Medi-Cal services and audit settlement-DHCS audit:1)initial cost reporting -after an internal review
by COUNTY, the COUNTY files cost report with DHCS on behalf of the PROVIDER'(s)legal entity
for the fiscal year; 2)Settlement -State reconciliation of records for paid Medi-Cal services,
approximately eighteen (18) to thirty-six (36) months following the State close of the fiscal year,
DHCS will send notice for any settlement under this provision will be sent to the COUNTY;and 3)
Audit Settlement-DHCS audit.After final reconciliation and settlement,COUNTY and/or DHCS may
conduct a review of medical records, cost report along with support documents submitted to
COUNTY in initial submission to determine accuracy and may disallow cost and/or unit of service
reported onthe PROVIDER'(s)legalentitycost report.COUNTY maychooseto appeal and
therefore reserves the right to defer payback settlement with PROVIDER(s) 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 PROVIDER(s), it will require the PROVIDER(s) 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 PROVIDER(s)
under this or any other Agreement.
C. Outcome Reports -PROVIDER(s)shall submit to COUNTY'S DBH service
outcome reports as requested by DBH. Outcome reports and outcome requirements are subject to
change at COUNTY DBH's discretion.
D.Additional Reports -PROVIDER(s)shall also furnish to COUNTY such
COUNTY OF FRESNO
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statements,records, reports, data, and other information as COUNTY'S DBH may request pertaining
to matters covered by this Agreement. In the event that PROVIDER(s)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,PROVIDER(s)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.
16.MONITORING
PROVIDER(s)agrees to extend to COUNTY'S staff,COUNTY'S DBH Director and
DHCS,or their designees,the right to review and monitor records,programs or procedures,at any
time, in regard to clients, as well as the overall operation of PROVIDER'(s)programs,in order to
ensure compliance with the terms and conditions of this Agreement.
17.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.
18.COMPLIANCE WITH STATE REQUIREMENTS
PROVIDER(s)recognizes that COUNTY operates its mental health programs under an
agreement with DHCS, and that under said agreement the State imposes certain requirements on
COUNTY and its PROVIDER(s)and its subcontractors.PROVIDER(s)shall adhere to all State
requirements, including those identified in Exhibit E "State Mental Health Requirements", attached
hereto and by this reference incorporated herein and made part of this Agreement.
19.COMPLIANCE WITH STATE MEDICAL REQUIREMENTS
PROVIDER(s)shall be required to maintain organizational provider certification by
Fresno County.PROVIDER(s)must meet Medi-Cal organization provider standards as listed in
Exhibit F,"Medi-Cal Organizational Provider Standards",attached hereto and by this reference
incorporated herein and made part of this Agreement. It is acknowledged that all references to
Organizational Provider and/or Provider in Exhibit F shall refer to PROVIDER(s). In addition,
PROVIDER(s)shall inform every client of their rights under the COUNTY'S Mental Health Plan as
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described in "Fresno County Mental Health Plan Grievances and Appeals Process"Exhibit G,attached
hereto and by this reference incorporated herein and made part of this Agreement.PROVIDER(s)
shall also file an incident report for all incidents involving clients,following the Protocol for
Completion of Incident Report and using the Worksheet identified in the "Fresno County Mental
Health Plan Incident Reporting",Exhibit H,attached hereto and by this reference incorporated herein
and made part of this Agreement,or a protocol and worksheet presented by PROVIDER(s)that is
accepted by COUNTY'S DBH Director,or designee.
20.CONFIDENTIALITY
All services performed by PROVIDER(s)under this Agreement shall be in strict
conformance with all applicable Federal,State of California and/or local laws and regulations relating
to confidentiality.
21-HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and PROVIDER(s)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 PROVIDER(s)acknowledge that the exchange of PHI between them is only
for treatment,payment,and health care operations.
COUNTY and PROVIDER(s)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
PROVIDER(s)to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to,Title 45,sections 164.314(a),164.502(e)and 164.504(e)of the Code
of Federal Regulations (CFR).
22.DATA SECURITY
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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 PROVIDER(s)by the COUNTY,including but not limited to the following:
A.PROVIDER(s)-Owned Mobile,Wireless,or Handheld Devices
PROVIDER(s)may not connect to COUNTY networks via personally-owned
mobile,wireless or handheld devices,unless the following conditions are met:
1)PROVIDER(s)has received authorization by COUNTY for
telecommuting purposes;
2)Current virus protection software is in place;
3)Mobile device has the remote wipe feature enabled;and
4) A secure connection is used.
B.PROVIDER(s)-Owned Computers or Computer Peripherals
PROVIDER(s)may not bring PROVIDER(s)-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY'S Chief
Information Officer, and/or designee(s),including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection.Said data must be encrypted.
C.COUNTY-Owned Computer Equipment
PROVIDER(s)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.PROVIDER(s)may not store COUNTY'S private,confidential or sensitive data
on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
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E.PROVIDER(s)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.PROVIDER(s)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 PROVIDER(s)response to all incidents
arising from a possible breach of security related to COUNTY'S confidential client information
provided to PROVIDER(s).PROVIDER(s)will be responsible to issue any notification to affected
individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
PROVIDER(s)will be responsible for all costs incurred as a result of providing the required
notification.
23.PROPERTY OF COUNTY
A.COUNTY and PROVIDER(s)recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY'S Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one (1)year.Depreciation of the qualified
items will be on a straight-line basis.
For COUNTY purposes,fixed assets must fulfill three (3)qualifications:
1.Asset must have life span of over one (1)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:
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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 assetitwillbe taggedwitha COUNTY program number.A Fixed
assetlogwillbe maintained by COUNTY'S Asset Management Systemand annual inventoried until
theassetis fully depreciated.During thetermsofthis Agreement,PROVIDER(s)fixed assets may be
inventoried in comparison to COUNTY'S DBH Asset Inventory System.
B.Certain purchases lessthanFive Thousand and No/100 Dollars ($5,000.00)but
more than One Thousand and No/100 Dollars ($1,000.00), with over one (1) year life span, and are
mobile andhighriskoftheftor lossare sensitive assets.Such sensitive items arenot limited to
computers,copiers,televisions,cameras andother sensitive items as determined by COUNTY'S DBH
Director,or designee.PROVIDER(s)maintains a tracking system onthe items andarenot required to
be capitalize or depreciated.The itemsaresubjectto 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.PROVIDER(s)agrees to participate in
anannual inventory of all COUNTY fixedand inventoried assets.Upon termination or expiration of
this Agreement,PROVIDER(s)shallbe physically presentwhenfixedand inventoried assetsare
returned to COUNTY possession.PROVIDER(s)is responsible forreturningto COUNTY all
COUNTY-owned undepreciated fixed and inventoried assets,orthe monetary value of said assets if
unable to produce the assets at the expiration or termination of this Agreement.
PROVIDER(s)further agrees to the following:
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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 PROVIDER(s)with funds provided
hereunder shall require the prior written approval of COUNTY'S DBH, shall fulfill the provisions of
this Agreementas appropriate,and must be directly relatedto PROVIDER(s)servicesor activity
under the terms of this Agreement. COUNTY'S DBH may refuse reimbursement for any costs
resultingfrom equipmentpurchased,whichare incurred by PROVIDER(s), if prior written approval
has not been obtained from COUNTY.
E.PROVIDER(s)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
wholeor in part, using funds underthis agreement. If any real or personal propertyacquiredor
improvedwith said funds identifiedherein is sold and/or is utilized by PROVIDER(s)for a use which
does not qualify under this program, PROVIDER(s) shall reimburse COUNTY in an amount equal to
the current fair market value of the property,less any portion thereof attributable to expenditures of
non-program funds. These requirements shall continue in effect for the life of the property. In the
event the program is closed out, the requirements for this Section Twenty-One (21)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."
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24.NON-DISCRIMINATION
Duringthe performanceof this Agreement,PROVIDER(s)shall not unlawfully
discriminateagainst any employeeor applicant for employment,or recipient of services,becauseof
race, religion,color, nationalorigin, ancestry,physical handicap,medicalcondition, maritalstatus,age
or sex, pursuant to all applicable State and Federal statutes and regulations.
25.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, PROVIDER(s)shall comply with:
A.Title 6 of the Civil Rights Act of 1964 (42 U.S.C.section 2000d,and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
and participation in federally funded programs through the provision of comprehensive and quality
bilingual services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients,including,but not limited to,assessing
the cultural and linguistic needs of its clients,training of staff on the policies and procedures,and
monitoring its language assistance program.The PROVIDER(s)procedures must include ensuring
compliance of any sub-contracted providers with these requirements.
C.PROVIDER(s)shall not use minors as interpreters.
D.PROVIDER(s)shall provide and pay for interpreting and translation services to
persons participating in PROVIDER(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 PROVIDER(s).Interpreter and translation services,including translation of
PROVIDER(s)"vital documents"(those documents that contain information that is critical for
accessing PROVIDER(s)services or are required by law) shall be provided to participants at no cost to
the participant.PROVIDER(s)shall ensure that any employees,agents,subcontractors,or partners
who interpret or translate for a program participant,or who directly communicate with a program
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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 PROVIDER(s)services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health,PROVIDER(s)must submit to
COUNTY for approval,within sixty (60) days from date of contract execution,PROVIDER(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
PROVIDER(s)shall include collection of documentation to ensure all national standards are
implemented.As the national competency standards are updated,PROVIDER(s)plan must be
updated accordingly.
26.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)(l)[I]),until the expiration of four (4)
yearsafter the furnishingof services underthis Agreement, PROVIDER(s)shall makeavailable,upon
writtenrequestof the Secretaryof the United States Departmentof Healthand Human Services,or
uponrequestof the Comptroller Generalof the United States General AccountingOffice,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
PROVIDER(s)under this Agreement.PROVIDER(s)further agrees that in the event PROVIDER(s)
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 Agreementshall contain a clause to the effect that until the expirationof four(4)
years after the furnishing of such services pursuant to such subcontract, the related organizations shall
make available, upon written request of the Secretary of the United States Department of Health and
Human Services, or upon request of the Comptroller General of the United States General Accounting
Office, or any of their duly authorized representatives,a copy of such subcontract and such books,
documents, and records of such organization as are necessary to verify the nature and extent of such
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costs.
27.SINGLE AUDIT CLAUSE
A.If PROVIDER(s)expends Seven Hundred Fifty Thousand Dollars ($750,000)or
more in Federal and Federal flow-through monies,PROVIDER(s)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.PROVIDER(s)shall submit said audit and management letter to
COUNTY.The audit must include a statement of findings or a statement that there were no findings.
If there are negative findings,PROVIDER(s)must include a corrective action plan signed by an
authorized individual.PROVIDER(s)agrees to take action to correct any material non-compliance or
weakness found as a result of such audit.Such audit 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 PROVIDER(s).All audit costs related to this Agreement are the
sole responsibility of PROVIDER(s).
B. A single audit report is not applicable if PROVIDER(s)Federal contracts do not
exceed the Seven Hundred Fifty Thousand Dollars ($750,000)requirement or PROVIDER(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 PROVIDER(s) to
COUNTY as a minimum requirement to attest to PROVIDER(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 PROVIDER(s) who agrees to take corrective action to eliminate any material
noncompliance or weakness found as a result of such audit. Audit work performed by COUNTY
under this section shall be billed to the PROVIDER(s)at COUNTY'S cost, as determined by
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COUNTY'S Auditor-Controller/Treasurer-Tax Collector.
C.PROVIDER(s)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.
28.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if PROVIDER(s)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,
and455.106(a)(l),(2).
In accordance with C.F.R.,Title 42 §§455.101, 455.104,455.105 and 455.106(a)(l),(2),
the following information must be disclosed by PROVIDER(s) by completing Exhibit I, "Disclosure
of Ownership and Control Interest Statement", attached hereto and by this reference incorporated
herein and made part of this Agreement. PROVIDER(s) shall submit this form to COUNTY'S DBH
withinthirty (30)days of the effective date of this Agreement.Additionally,PROVIDER(s)shall
report any changes to this information within thirty-five (35)daysof occurrence by completing
Exhibit I,"Disclosure of Ownership and Control Interest Statement." Submissions shall be scanned
pdf copiesand are to be sent via email to DBHAdministration@co.fresno.ca.us attention: Contracts
Administration.
29.DISCLOSURE -CRIMINAL HISTORY AND CIVIL ACTIONS
PROVIDER(s) 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
"PROVIDER(s)"):
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
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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
PROVIDER(s) 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 PROVIDER(s)electsto submitwiththe disclosed information willbe
considered.If it is later determined that the PROVIDER(s)failed to disclose required information,
any contract awarded to such PROVIDER(s)may be immediately voided and terminated for
material failure to comply with the terms and conditions of the award.
PROVIDER(s)mustsigna "Certification Regarding Debarment,Suspension,and
Other Responsibility Matters-Primary Covered Transactions"in the form set forth in Exhibit J,
attached heretoandbythis reference incorporated herein.Additionally,PROVIDER(s)must
immediately advise the County in writing if,during the term ofthis Agreement:(1)PROVIDER(s)
becomes suspended,debarred,excluded or ineligible for participation in federal or state funded
programs or from receiving federal funds as listed inthe excluded parties' list system
(http://www.sam.gov);or(2)any ofthe above listed conditions become applicable to PROVIDER(s).
PROVIDER(s)shall indemnify,defend andholdthe COUNTY harmless foranylossor damage
resulting from a conviction,debarment,exclusion,ineligibility or other matter listed in the signed
CertificationRegardingDebarment,Suspension,and Other ResponsibilityMatters.
30.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the PROVIDER(s)is operating as a corporation (a
for-profit or non-profit corporation)or if during the term of this agreement,the PROVIDER(s)
changes its status to operate as a corporation.
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Clients of the PROVIDER(s)Board of Directors shall disclose any self-dealing
transactions that they are a party to while PROVIDER(s)is providing goods or performing services
under this agreement.A self-dealing transaction shall mean a transaction to which the PROVIDER(s)
is a party and in which one or more of its directors has a material financial interest.Clients of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
and signing a Self-Dealing Transaction Disclosure Form (Exhibit K attached hereto and by this
reference incorporated herein and made part of this Agreement)and submitting it to the COUNTY
prior to commencing with the self-dealing transaction or immediately thereafter.
31.COMPLIANCE
PROVIDER(s)shall comply with all requirements of the "Fresno County Mental Health
Compliance Program and PROVIDER(s)Code of Conduct and Ethics" as set forth in Exhibit C.
Within thirty (30) days of entering into this Agreement with the COUNTY,PROVIDER(s)shall have
all of PROVIDER(s)employees,agents and subcontractors providing services under this Agreement
certify in writing, that they have received, read, understood, and shall abide by the requirements set
forth in Exhibit C.PROVIDER(s)shall ensure that within thirty (30) days of hire, all new employees,
agents and subcontractors providing servicesunderthis Agreement certifyin writingthattheyhave
received, read,understood,and shall abide by the requirements set forth in Exhibit C.PROVIDER(s)
understands that the promotion of and adherenceto such requirementsis an element in evaluatingthe
performance of PROVIDER(s) and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees,agentsand subcontractors providingservicesunderthis Agreementshall complete general
compliance trainingand appropriate employees,agentsand subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual
whois required to attend training shallcertifyin writingthat heor shehas received the required
training.The certification shall specify thetypeof training received andthe date received.The
certification shall be provided to the COUNTY'S Compliance Officer at 3133 N. Millbrook, Room
171,Fresno, CA 93703. PROVIDER(s) agrees to reimburse COUNTY for the entire cost of any
COUNTY OF FRESNO
Fresno,CA
penalty imposed upon COUNTY by the Federal Government as a result of PROVIDER(s)violation of
the terms of this Agreement.
32.ASSURANCES
In entering into this Agreement,PROVIDER(s)certifies that it nor any of its officers are
not currently excluded,suspended,debarred,or otherwise ineligible to participate in the Federal
Health Care Programs:that it or any of its officers have not been convicted of a criminal offense
related to the provision of health care items or services;nor has it or its officers been reinstated to
participation in the Federal Health Care Programs after a period of exclusion,suspension, debarment,
or ineligibility. If COUNTY learns, subsequent to entering into a contract, that PROVIDER(s) is
ineligible on these grounds, COUNTY will remove PROVIDER(s) from responsibility for, or
involvement with, COUNTY'S business operations related to the Federal Health Care Programs and
shall remove such PROVIDER(s)from any position in which PROVIDER(s)compensation,or the
items or services rendered, ordered or prescribed by PROVIDER(s)may be paid in whole or part,
directly or indirectly,by Federal Health Care Programs or otherwise with Federal Funds at least until
such time as PROVIDER(s)is reinstated into participation in the Federal Health Care Programs.
A. If COUNTY has notice that PROVIDER(s)or its officers has been charged with
a criminaloffenserelated to any FederalHealth Care Program,or is proposed forexclusion during
the termon any contract, PROVIDER(s)and COUNTYshall take all appropriateactionsto ensure
the accuracy of any claims submittedto any FederalHealth Care Program. At its discretion given
such circumstances, COUNTY may request that PROVIDER(s) cease providing services until
resolution of the charges or the proposed exclusion.
B. PROVIDER(s) agrees that all potential new employees of PROVIDER(s) or
subcontractors of PROVIDER(s)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 ineligibleto participate in the Federal Health Care Programs;(2)
theyhavebeenconvictedof a criminaloffenserelatedto the provision of healthcareitemsor services;
andor (3)theyhavebeenreinstatedto participation in the Federal HealthCare Programs aftera period
of exclusion,suspension,debarment,or ineligibility.
-31 -COUNTY OF FRESNO
Fresno,CA
1.In the event the potential employee or subcontractor informs
PROVIDER(s)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 PROVIDER(s)hires or engages
such potential employee or subcontractor,PROVIDER(s)will ensure that
said employee or subcontractor does no work,either directly or indirectly
relating to services provided to COUNTY.
2.Notwithstanding the above,COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement,or require
adequate assurance (as defined by COUNTY) that no excluded, suspended
or otherwise ineligible employee or subcontractor of PROVIDER(s)will
perform work, either directly or indirectly, relating to services provided to
COUNTY.Such demand for adequate assurance shall be effective upon a
time frame to be determined by COUNTY to protect the interests of
COUNTY clients.
C.PROVIDER(s)shall verify (by asking the applicable employees and
subcontractors)that all current employeesand existing subcontractorswho, in each case, are expected
to performprofessionalservices underthis Agreement:(1) are not currentlyexcluded,suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have
notbeen reinstatedto participation in the Federal HealthCare Programafter a periodof exclusion,
suspension,debarment,or ineligibility.Intheeventanyexisting employee or subcontractor informs
PROVIDER(s) 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,PROVIDER(s)will ensure thatsaid employee or subcontractor does
no work,either direct or indirect,relating to services provided to COUNTY.
1.PROVIDER(s)agrees to notify COUNTY immediately during the term
of this Agreement whenever PROVIDER(s) learns that an employee or
-32 -COUNTY OF FRESNO
Fresno,CA
subcontractor who, in each case, is providing professional services under
Section 1 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 PROVIDER(s)will
perform work,either directly or indirectly,relating to services provided to
COUNTY.Such demand for adequate assurance shall be effective upon a
time frame to be determined by COUNTY to protect the interests of
COUNTY clients.
D.PROVIDER(s)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 PROVIDER(s)compliance with the provisions of this Section 32.
E.PROVIDER(s)agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of PROVIDER(s) violation of
PROVIDER(s)obligations as described in this Section 32.
33.COMPLAINTS
PROVIDER(s)shall log complaints and the disposition of all complaints from a client or
a client's family.PROVIDER(s)shall provide a copy of the detailed complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th)day of the following
month,in a format that is mutually agreed upon.Besides the detailed complaint log,PROVIDER(s)
shall provide details and attach documentation of each complaint with the log. PROVIDER(s) shall
postsigns informingclients of their right to file a complaint or grievance. PROVIDER(s)shallnotify
COUNTY of all incidents reportable to state licensing bodies that affect COUNTY clients within
twenty-four (24) hours of receipt of a complaint.
33 -COUNTY OF FRESNO
Fresno,CA
Within ten (10)days after each incident or complaint affecting COUNTY-sponsored
clients,PROVIDER(s)shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint,the complaint and PROVIDER(s)disposition of, or corrective
action taken to resolve the complaint.In addition,PROVIDER(s)shall inform every client of their
rights as set forth in Exhibit H.PROVIDER(s)shall file an incident report for all incidents involving
clients,following the Protocol and using the Worksheet identified in Exhibit I.
34.PROHIBITION ON PUBLICITY
None of the funds,materials,property or services provided directly or indirectly under
this Agreement shall be used for PROVIDER(s)advertising, fundraising, or publicity (i.e., purchasing
of tickets/tables,silent auction donations,etc.) for the purpose of self-promotion.Notwithstanding the
above, publicity of the services described in Section 1 of this Agreement shall be allowed as necessary
to raise public awareness about the availability of such specific services when approved in advance by
COUNTY'S DBH Director or designee and at a cost to be provided in Section 4 of this Agreement for
such items as written/printed materials, the use of media (i.e., radio, television, newspapers) and any
other related expense(s).
35.SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create a
joint ventureamong PROVIDER(s).Byexecution of this Agreement, PROVIDER(s)understand that a
separate Agreement is formed between each individual PROVIDER and COUNTY.
36.AUDITS AND INSPECTIONS
PROVIDER(s)shall at any time during business hours, and as often as the COUNTY
maydeem necessary,make available to the COUNTY for examination all of its records anddatawith
respectto the matters covered by this Agreement. PROVIDER(s)shall, upon requestby the
COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to ensure
PROVIDER(s)compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
PROVIDER(s) shall be subject to the examination and audit of the State Auditor General for a period
of three (3) years after final payment under contract (Government Code section 8546.7).
34 -COUNTY OF FRESNO
Fresno,CA
37.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY PROVIDER(s)
Director,Fresno County (See Exhibit A)
Department of Behavioral Health
4441 E.Kings Canyon Rd
Fresno,CA 93702
Any and all notices between the COUNTY and the PROVIDER(s)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.
38.GOVERNING LAW
The parties agree that for the purpose of venue,performance under this Agreement is in
Fresno County,California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
39.ENTIRE AGREEMENT
This Agreement,including all Exhibits,constitutes the entire agreement between
PROVIDER(s)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.
///
///
///
///
///
///
///
COUNTY OF FRESNO
Fresno,CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
3
4 PROVIDER(s)
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
SEE ATTACHED EXHIBIT A
COUNTY OF FRESNO
By~~~~~~~~~~~~-
Deborah A. Poochigian
Chairman, Board of Superviso s
Date: ~~~ ,/Wt§
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
-36 -COUNTY OF FRESNO
Fresno, CA
1
2
3
4
5
APPROVED AS TO LEGAL FORM:
DANIEL C. CEDERBORG, COUNTY COUNSEL
By~
6 APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
7 TREASURER-TAX COLLECTOR
8
9
10
11
12
13.
REVIEWED AND RECOMMENDED FOR APPROVAL:
14 By-----=~-=----____:______,1_Uv~_M-d __ _
15 Dawan Utecht, Director
Department of Behavioral Health
16
17
Fund/Subclass: 0001110000
Account/Program: 7223/0
Organizations/Cost Centers: 56302666
18
19
20
21
22
23
24
Fiscal Year (FY) Program Cost
25
26
27
28
FY 15-16
FY 16-17
FY 17-18
FY 18-19
FY 19-20
Total
$3,500,000
$3,500,000
$3,605,000
$3,713,150
$3,824,545
$18,142,695
-37 -
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
COUNTY OF FRESNO
Fresno, CA
Individual Providers
Name Address
Al-Saoudi,Yuleen 516 Villa Suite #3 Clovis,CA 93612-
Amling-Heiken,Jane 5464 N.Palm #B Fresno,CA 93704-
Armer,Justin 614 N.St Sanger,CA 93657-
Avina,Erica 614 N.Street Sanger,CA 93657-
Bergstrom,Virginia 5588 N.Palm Fresno,CA 93704-
Broesel,Rondi 4747 N.First,Suite 119 Fresno,CA 93726-
Brookins,Antionette 3723 E.Dakota Fresno,CA 93726-
Cardoza,Julie 2490 W.Shaw Ave Suite 101 Fresno,CA 93710
Case,Gabriele 4420 N.First #121 Fresno,CA 93726-
Casillas,Jennell A.6225 N.First Street Suite 103 Fresno,CA 93710
Dickey,Judith 5707 N.Palm #103 Fresno,CA 93704
Fulton,Tracy 5464 N Palm Ave,Ste # B Fresno,CA 93704-
Garvey,Catherine 5475 N.Fresno Street Fresno,CA 93710
Glidden,Howard,Dr.1660 E.Herndon #150 Fresno,CA 93720-
Gordon-Mcintosh,Wanda 5588 N.Palm Ave Fresno,CA 93704-
Haider,Shazina,Dr.416 W Bluff Ave Fresno,CA 93711
Jackson-Salcedo,Peggy, Dr.1586 N.Van Ness Fresno,CA 93728-
Johnson,David 3097 Willow Ave Suite #4 Clovis,CA 93612-
Lopez,Jeanette 2008 N.Fine #103 Fresno,CA 93727-
Lose,Linda 1305 W.Bullard #11 Fresno,CA 93704-
Malin,Matthew 264 Clovis Ave Ste 212 Clovis,CA 93612-
Mar,Jeffrey,Dr.5100 N.Sixth #135 Fresno,CA 93710
Pacheco,Myrna 5588 N.Palm Ave Fresno,CA 93704-
Powroznik,James 5588 N.Palm Ave Suite P4 Fresno,CA 93704-
Qualle,Cordie Micah 264 Clovis Ave Ste 212 Clovis,CA 93612-
Randolph,Michelle 5070 N.Sixth #174 Fresno,CA 93710-
Roltgen,Teresa 2505 W.Shaw Fresno,CA 93711-
Romero,Jorge 5070 N.Sixth #174 Fresno,CA 93710-
Slagle,Laura 3114 Willow Ave Ste 102 Clovis,CA 93612-
Steele,Ronald 7005 N Milburn Ave,Suite 202,Fresno,CA 93722
Trujillo,Elinda 1713 Tulare St Suite 132 Fresno,CA 93721-
Xiong,Zoua 5588 N.Palm Avenue Fresno,CA 93704
Young,Perry 5707 N.Palm #103 Fresno,CA 93704-
Ziyar, Latif, Dr.7335 N.First #109 Fresno,CA 93720-
Group Providers
Name Address
Bashful Elephant Counseling 3097 Willow Ave Suite #4 Clovis,CA 93612-
Castani Family Services 5100 N.6th Ste 104 Fresno,CA 93710-
DN Associates 3457 W Shaw Ave #101 Fresno,CA 93711
Dunamis,Inc 4991 E.McKinley #112 Fresno,CA 93727-
Fresno Mental Health 1130 E.Shaw Ste 105 Fresno,CA 93710-
Generational Changes,1nc.2409 Merced Ste 106 Fresno,CA 93721-
House Psychiatric Clinic Inc 1322 E.Shaw #410 Fresno,CA 93710-
Kids Play Therapy,Inc.5100 N.Sixth #140 Fresno,CA 93710-
Page 1 of 1
Exhibit A
&
PROVIDER:Yuleen Al-Saoudi
By m{(s $f-SCi<&i<(3
Print Name:\\\eQ(\A\-Sl^h (f,
Title:LMr^T
Date:S /I f /<S~
Mailing Address:
516 Villa Suite #3
Clovis,Ca.93612
COUNTY OF FRESNO
Fresno,CA
3^
PROVIDER:Jane Amling-Heiken
lameJaniHniinaHei^ei
Title:L-TA <T.T
£~\q-\5Date:3
Mailing Address:
5464 N.Palm #B
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
IE-
PROVIDER:Justin Armerly/;...,-
Print Name:^^|K\--J.A\M.^S
Title:
^/lf/1^Date:
Mailing Address:
614 N.St
Sanger,Ca.93657
COUNTY OF FRESNO
Fresno,CA
H
PROVIDER:Erica Avina
By'
Print Name:B<\CJ^f\MVA^
Title:\^LAPr
Date:OQbVS
Mailing Address:
614 N.St
Sanger,Ca.93657
COUNTY OF FRESNO
Fresno,CA
Print Name:////fr /^,^/)tf rt&t/#/T?
Title:kmf~T
Date:57/9//.
Mailing Address:
5588 N.Palm
Fresno,CA 93704
->
COUNTY OF FRESNO
Fresno,CA
N3
PROVIDER:Rondi Broesel
By (jrndt i&tc^Mi
Print Name:/</>/fe//OfOP<>f
Title:A C C UJ
Date:5~/>n
Mailing Address:
4747 N.First,Suite 119
Fresno,CA 93726
COUNTY OF FRESNO
Fresno,CA
UU
PROVIDER:Antionette Brookins
By c K_^(?p.^^.-ok ':^v
Print Name:vA v>A '^^tiAix:~D •^r^<~Al-i---ac:-)
Title:L.v\V ~~1
Date:'O "^"|-\<-f
Mailing Address:
3723 E.Dakota
Fresno,CA 93726-
COUNTY OF FRESNO
Fresno,CA
H6
Julie Cardoza
Print Name:vfolUg,ddrdg&q UUPT
Title:LlUFT"
Date:£>\\Q\\5
Mailing Address:
2490 W.Shaw Ave Suite 101
Fresno,CA 93710
COUNTY OF FRESNO
Fresno,CA
4u
PROVIDER:Gabriele Case
By /ibicG Lik-
Print Name:UtSufkl (obyt
Title:j^CS^b
Date:b -H-lb
Mailing Address:
-4420N.Fiisl Z/K21
Fresno,CA 93736-//
COUNTY OF FRESNO
Fresno,CA
Lj*J
PROVIDER:Jennell A Casillas
By
Print Name:,TW^f(fjSllhS
Title:iMtrmi'6
Date:Klnixs
Mailing Address:
6225N.First Street,Suite 103
Fresno,CA 93710
COUNTY OF FRESNO
Fresno,CA
Ht>
PROVIDER:Judith Dickey
By /MMU/A
Print Name:tyM//'/tf
Title:f,/ft/r7'
Date:z-xo po/s
Mailing Address:
5707 N.Palm #103
Fresno,Ca.93704
COUNTY OF FRESNO
Fresno,CA
PROVIDER:Tracyjultoji
Print Name:"ft*^"\-vdl-m_
Title:LWlFr
"MhDate:S//S/JS
Mailing Address:
5464 N Palm Ave,Ste # B
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
so
PROVIDER:Katherine Garvey
By (/.cA->
Print Name:(_jQfTHYVU ,v<(y^tt\y^.^
Title:C^n/n
Date:
5 7-7 //v
Mailing Address:
5475 N Fresno Str.
Fresno,Ca.93710
COUNTY OF FRESNO
Fresno,CA
£i
PROVIDER:Howard Glidden
By
Print Name:HVuM.sd Gr liddf t
Title:tJ****>f)*>ytA'tou f /•*
Date:<T//^/t^n-
Mailing Address:
1660 E.Herndon#150
Fresno,CA 93720
COUNTY OF FRESNO
Fresno,CA
PROVIDER^Wanda Gordon-Mclntosh
By/s/y%4>(t
Print Kw*6(JftJ04-fi fofrstjAj ^f(ffo^s/i
Title
Date:5Vf-A-
Mailing Address:
5588 N.Palm Ave
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
S3
PROVIDER:Shazina Haider
By r>)>H~q4ciji^'?u-b
Print Name:6V/)4^-/AJ/t hh^/D^B
Title:CA^/C^J Pnryy <?J,V^^
Date:d//€>//S~
Mailing Address:
416 W.Bluff Ave.
Fresno,Ca.93711-6908
COUNTY OF FRESNO
Fresno,CA
^\
PRPVlDE^:Dr.Peggy^Jad^pn-Salcc
Print NameH £(=>(r>l|U.A lA CKZ0n -\><k |CA ^
^P .\I 1 Or i,_..t^R
Title:CiL.-\C4
Date:s
Mailing Address:
1586 N.Van Ness
Fresno,CA 93728
M>oit ?£Vr 1*7^i
s
COUNTY OF FRESNO
Fresno,CA
SS
PROVIDER:John
Print Name:jJ^iQ '^fet+M'^^
Title:L^F-7 '
Date:S'/ttfl(5
Mailing Address:
3097 Willow Ave Suite #4
Clovis,CA 93612
COUNTY OF FRESNO
Fresno,CA
£io
PROVIDER:Jeanette Lopez
By Q^Cz/yr c7ft yfct+nJspjj s>ft&fi£j-
Print Name:bJefpnetie^lamht/V IrrOe^
Title:/C6 h/
Date:S'2Q -^/C
Mailing Address:
2008 N.Fine #103
Fresno,CA 93727
COUNTY OF FRESNO
Fresno,CA
57
PROVIDERyOnda Lose
By r~&y-tf<t'M^-J(^?£.
Print Name:L~<nda-M LoS<L
Title:fnsovuajf,f J2t^L --^AJ^Ct^U}^
Date:,5W £-1-0
Mailing Address:
1305 W.Bullard#l
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
^
PROWDER\Matthew Kelly Malin
Print Name:[/\A C+t W^\!/\
Title:<-^pT
Date:4~\%-\$
Mailing Address:
264 Clovis Ave Ste.212
Clovis,Ca.93612
COUNTY OF FRESNO
Fresno,CA
tf
PROVIDER:Jeffrey B.Mar
Print Name:Jeftrsc^J/t A&./4?,\>
Title:F>Hjshale 4*5 1~^;ochohi'
*MDate:>//r//:>
Mailing Address:
5100 North sixth Street #135
Fresno,Ca.93710
COUNTY OF FRESNO
Fresno,CA
^0
PROVIDER:Myrna Pacheco
Date:5-1V1B
Mailing Address:
5588 N.Palm Avenue
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
Lr\
James Powroznik
By ^Jk3L/r>*v>i_U \\>^s^A
Print Name:-X&<-vs3 ft.Vut^^VMC
Title:LnfV
Date:S-l^-(S"
Mailing Address:
5588 N.Palm Ave
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
PROVIDER:Cordie Micah Qualle
By
Print Name:Lorc/iC MiOyU (j^l^
Title:^~^F"T
Date:^'W I *C
Mailing Address:
264 Clovis Ave #202
Clovis Ca 93612
COUNTY OF FRESNO
Fresno,CA
i/3
PROVIDER:Michelle Randolph
By \/>^Lwl
MollS.^
Date:S C2-V5
Mailing Address:
5100 N Sixth Street
Fresno,Ca.93710
Print Name:\I M Y\C-Uc,.^GjfXXbfl"
Title:Vx.VI ^lC
COUNTY OF FRESNO
Fresno,CA
L*1
PROVIDER:Teresa Roltgen
By {Jbjj22jtU C
Print Name:/gre^Q S--w(4fCl
Title:jytfFT
Date:S ~/f '/S
Mailing Address:
2505 W.Shaw Avenue
Fresno,CA 93711
COUNTY OF FRESNO
Fresno,CA
Ub
PROVIDER:Jorge Romero
Print Name:J^6 A fOtA^jUi
Title:L \A^T
Date:CfllH/^Cir
Mailing Address:
5070 N Sixth Street,Suite 174
Fresno,CA 93710
COUNTY OF FRESNO
Fresno,CA
PROVIDER:Laura Slagle
By ^OJJLA*
Print Name:LctUVO ^l^tfll^.
Title:U VW FT
Date:05 j fl |iS
Mailing Address:
3114 Willow Avenue,Suite 102
Clovis,CA 93612
COUNTY OF FRESNO
Fresno,CA
bl
PROVIDER:Ron C Steele
By
Print Name:K#/V S^t^tfLtf //3W
Title:QU/Nf^.
Mailing Address:
7005 N.Milburn Avenue,Suite 202
Fresno,CA 93722
COUNTY OF FRESNO
Fresno,CA
PROVIDER:Erlinda Trujillo
By a.QjUit e^J&
Print Name:£V,/,V)J/)T(l uj i ltd
Title:K CS>iJ
Date:^>-c£O-/5
Mailing Address:
2848 Mariposa Street
Fresno,CA 93721
COUNTY OF FRESNO
Fresno,CA
1S1
Zoua Xiong
Print Name:~2-(J\Jt\Ju
Title:fj^QMMd hltmAJtUt ^(/f^Jy "Jl^iC^d
Date:s/l^/fS
Mailing Address:
5588 N.Palm Ave
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
no
PROVIDER:Perry Young
Title:/m^c ^n^&i
Date:^-\°)^^c=>[^
Mailing Address:
5707 N.Palm Avenue,Suite 103
Fresno,CA 93704
COUNTY OF FRESNO
Fresno,CA
t~1
PROVIDER:LatifZiyar
By
Print Name:LfuYf-?-?y flK-
-I >
Title:pvtyiOe*-t
Date:9 -H'^
Mailing Address:
7335 N.First Street,Suite 109
Fresno,CA 93720
COUNTY OF FRESNO
Fresno,CA
7^
PROVIDER:BASHFUL ELEPHANT COUNSELING
By
Print NameJ-Pdjnt/d \OV J^&Ut
Title:Lrv\rT
Chairman of the Board,or
President,or any Vice President
d fakjuLJL^j u>
Date:f'lti'lf
By:
Print Name:
Title:
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
COUNTY OF FRESNO
Fresno,CA
73
PROVIDER:CASTANI FAMILY SERVICES
By ^KJ^SJK^CUlu-r^h^/CAA fJT
Print Name:lg?t(%nc tk.,M\)(7\f-&2b-
Title:/,fJ\<^V
Chairman of the Board,or
President,or any Vice President
Date:^//g /^Q^
By:
Print Name:
Title:
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
COUNTY OF FRESNO
Fresno,CA
74
Mailing Address:
3457 W Shaw Ave #101
Fresno,CA 93711
PROVIDER:DN Associates
By
•C 'ntvrt s LPrintName:'€>hs£\J AKi
Title:
Date:
By:
~J>,fZ.v$<-—£>
Chairman of the Board,or
President,or any Vice President
^I ct |cr
Print Name:
Title:
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
COUNTY OF FRESNO
Fresno,CA
16
PROVIDER:DUNAMIS,INC.
Print Name:Q%\g t\rf 0 Qiii^h^
Title:C^O
Chairman of the Board,or
President,or any Vice President
Date:3")->—/5
By:
Print Name:
Title:
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
Mailing Address:
4991 E.McKinley,Suite 112
Fresno,CA 93727
-i COUNTY OF FRESNO
Fresno,CA
nb
PROVIDER:FRESNO MENTAL HEALTH
Print Name:AA/mai ^-"T7Vy/g?
Title:
Date:
By:
(A\^p
Chairman of the Board,or
President,or any Vice President
rfcrfnr
Print Name:
Title:
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
COUNTY OF FRESNO
Fresno,CA
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PROVIDER:GENERATIONAL CHANGES,INC.
By.
Print Name:/^^//(/,sAf^l
™e:OSi
Chairman of the Board,or
President,or any Vice President
Date:<~/£r~^<T
By:_
Print Name:AA ^/aA<:
Title:fif%
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
1 -COUNTY OF FRESNO
Fresno,CA
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PROVIDER:HOUSE PSYCHIATRIC CLINIC,INC.
By
Print Name:tMrt7Tr*&C A^^^^O.
Title:^sYSidevy4-
Chairman of the Board,or
President,or any Vice President
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Date:
5-iC)-\S
By:
Print Name:
Title:
Secretary (of Corporation),or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
COUNTY OF FRESNO
Fresno,CA
PROVIDER:KIDS PLAY THERAPY,INC.
Print NameTtV^LinLA Po.(A )fl_44*5>
Title:HCXJAS "
Chairman of the Board,or
President,or any Vice President
Date:C\>-/6~/^
By:
Print Name:
Title:
Secretary (of Corporation), or
any Assistant Secretary,or
Chief Financial Officer,or
any Assistant Treasurer
COUNTY OF FRESNO
Fresno,CA
fc*>
Fresno County Mental Health Plan
Individual and Group Provider Fee Schedule
Effective 1/2014
Exhibit B
Page 1 of 1
Avatar
Service
Service Description Codes Rate/min Flat Rate
Psychiatrist
MD Meds Eval Mngt Assessment (up to 120 min)170 $4.23 N/A
N/AMDReauthorizationincludingplandevelopmentonly(up to 60 min)170 $4.23
MD Med Eval Mngt Brief 172
173
$4.23
$4.23
N/A
N/AMDMedsEvalMngtFollow-Up
Individual Medical Psychotherapy 126 $1.20 N/A
Hospital Care -Inpatient -New/Established (flat rate)839 N/A $100.00
Hospital Care -Subsequent -Bedside (flat rate)840 ^._.N/A___.$55.00
Inpatient Consultation - Initial -New/Established 822 $1.27 N/A
Emergency Department 823 "$1.17 N/A
Nursing Facility Assessment 825 $1.42 N/A
Subsequent Nursing Facility 828 $1.67 N/A
Individual Assessment
Group Therapy
r 103 $1.20 N/A
82
83
$1.53
$1.27
$0.95
N/A
N/A
N/A
Individual or Family Psychotherapy
Family Therapy 156
Collateral 150 $1.00 N/A
Case Management / Linkage &Consult 205 $0.67 N/A
Psychologist
N/A
N/A
Individual Assessment 103
83
$0.95
$1.53Individualor Family Psychotherapy
Group Therapy 82 $1.53
$0.87
$1.00
$0.67
$0.95
N/A
N/ATestAdministrationIncludingPre-lnterview 891
150Collateral N/A
N/A
N/A
Case Management / Linkage &Consult 205
159PlanDevelopment
Rehabilitation
LCSW,LMFT,LPCC,RN -MS
158 $0.95 N/A
103 ~"$0.9~5"~N/AIndividualAssessment
Individual or Family Psychotherapy 83 $0.95 N/A
Group Therapy 82 $1.53 N/A
Collateral 150 r $i.oo N/A
N/ACaseManagement/ Linkage &Consult 205 $0.67
Plan Development
Rehabilitation
159
158
$0.95 N/A
$0.95 N/A
Services for Court Referred Cases
Psychologist
^96^
f"97 -
Psychological Evaluation (10 hours Max)$0.95
_.P035
$0.95
N/A
N/A
N/A
All Disciplines
Bonding Study 1or II (10 hours maximum)
Family Psychodynamic Formulation (10 hours maximum)98
Attachment Assessment (10 hours maximum)99 $0.95 N/A
Quarterly Report 3QR
3CR
3CT
N/A
N/A
N/A
$40.00/report
$54.00/report
$54/hour
Court Report
Court testimony (per hour of testimony)
t>\
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.
03
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: / /_
M
Documentation Standards For Client Records
Exhibit D
Page 1 of 3
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 followingareas will be includedas appropriateas a part of a comprehensiveclientrecord.
• Relevantphysicalhealth conditionsreported by the client will be prominentlyidentified
and updated as appropriate.
•Presenting problemsand relevant conditions affectingthe client's physical healthand
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 riskto clientsorotherswillbe 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.
• Clientselfreportof allergies and adverse reactions to medications,or lackof known
allergies/sensitivities will be clearly documented.
• A mental healthhistorywillbe documented,including:previoustreatment dates,
providers,therapeutic interventions and responses,sources of clinical data,relevant
family information and relevant results of relevant labtestsand consultations reports.
• For children and adolescents,pre-natal and perinatal eventsandcomplete developmental
history will be documented.
•Documentations will include pastand 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 fromthe most current DSM,or a diagnosis from the most current
ICD,will be documented,consistent with the presentingproblems,history mental status
evaluation and/or other assessment data.
2.Timeliness/Frequency Standard for Assessment
•
•
An assessment willbe 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
Exhibit D
Page 2 of 3
1.Client plans will:
• 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
0^
Exhibit D
Page 3 of 3
• 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 orjob 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
2.Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency bytypeof service indicated below:
A.Every Service Contact
•Mental Health Services
•Medication Support Services
•Crisis Intervention
ei
Exhibit E
Page 1 of 2
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 limitedto confidentialityof information
requirements at 42, Codeof 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;andDivision 1,Part2.6,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 eligibilityrequirementsto participatein the programplan 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 preferencein
employment practices. Such practices includeretirement,recruitment
advertising,hiring,layoff,termination,upgrading,demotion,transfer,
Exhibit E
Page 2 of 2
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 consentof COUNTY'SDepartmentof BehavioralHealth
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 limitedto, laws, regulations,and State policies relatingto patients' rights
^c^
Exhibit F
Page 1 of 2
Medi-CalOrganizational ProviderStandards
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 orstaff 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 bythe provider and used for services orstaffto 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 ina 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 toa psychiatrist
when necessary,or to a physician,if a psychiatristis not available.
9.The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described inTitle9,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 labelsarealteredonly bypersonslegally 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.
")D
Exhibit F
Page 2 of 2
D. Drugsare stored in a lockedarea with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugsare not retained afterthe expiration date.IM multi-dose vialsaredatedand
initialed when opened.
F. A drug log is maintained to ensurethe providerdisposesof expired,contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G.Policies and procedures are in placefor dispensing,administering and storing
medications.
11.For organizational providers that provide day treatment intensive orday rehabilitation,the
provider must have a written description oftheday treatment intensive and/or day treatment
rehabilitation program that complies withState Department of HealthCareService'sday
treatment requirements.The COUNTY shallreviewthe provider's written program
description for compliance with the State Department of Health Care Service's day
treatment requirements.
12.The COUNTY mayacceptthe hostcounty's site certification and reserves the rightto
conduct an on-site certification review at least every three (3) 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 inthe physical plant ofthe provider site (some physical
plantchangescould require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusualevents, accidents,or injuriesrequiringmedical treatment for clients,
staff or members of the community.
^
Exhibit G
Page 1 of 2
Fresno County Mental Health Plan Grievances and Appeals Process
The 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.
Title9 ofthe California Code of Regulations requires that the MHPand its fee-for-
service providers to giveverbal 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 locationswhere 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.
Beneficiarieshave 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 mustbe available for
beneficiaries to pick up at all provider sites without having to make a verbal or written
request.Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O.Box 45003
Fresno,CA 93718-9886
(800)654-3937 (for more information)
(559)488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple,informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other complaints and
concerns.
^
Exhibit G
Page 2 of 2
Informal providerproblem 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).
Formalprovider 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,whenthe complaint concerns a deniedor modified request for MHP
payment authorization,orthe process or paymentofa 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
paymentofa provider's claim to the MHP.The written appeal must be submitted to the
MHP within ninety (90)calendar days ofthe date ofthe receiptofthe non-approval of
payment.
The MHP shall have sixty (60)calendar days from its receipt ofthe appeal to inform the
provider in writing ofthe decision,including a statement ofthe 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 ofpayment authorization request, the
MHP utilizes Managed Care staff who were not involved inthe 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 thirty (30)calendar days of receipt ofthe
decision
Othercomplaints - if there are other issues or complaints,which are not related to
payment authorization issues,providers are encouraged to send a letterof complaint to
the MHP.The provider will receive a written response from the MHP within sixty (60)
calendar days of receiptofthe complaint.The decision rendered buythe MHP is final.
i*
Exhibit H
Page 1 of 2
Fresno County Mental Health Plan
Incident Reporting
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form,and the supervisor co-signs it.
•When more than one client is involved in an incident,a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
•Incident Report should be sent to:
DBH Program Supervisor
1l
Exhibit H
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 keypeople 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 I I 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
<lS
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
Exhibit I
Page 1 of 3
I.Identifying Information
Name of entity
Address (number,street)City ZIP code
CUA number Taxpayer ID number (EIN)Telephone number
(
II.Answer the following questions by checking "Yes"or "No."If any ofthe questions are answered "Yes,"list names and
addresses of individuals or corporations under "Remarks"onpage 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 ofa criminal
offense related to the involvement of such persons or organizations in any of the programs established
by Titles XVIII,XIX,or XX?
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 byTitles XVIII,XIX,or XX?
Are there any individuals currently employed by the institution,agency,or organization in a managerial,
accounting,auditing,or similar capacity who were employed by the institution's,organization's,or
agency's fiscal intermediary or carrier within the previous 12 months?(Title XVIII providers only)
YES NO
A.List names,addresses for individuals,or the EIN for organizations having direct or indirect ownership ora 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:
a Sole proprietorship
•Unincorporated Associations
n Partnership
a Other (specify).
3 Corporation
D.
If the disclosing entity is a corporation,
under "Remarks."
st names,addresses of the directors,and EINs for corporations
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 o
NAME ADDRESS PROVIDER NUMBER
^y
Exhibit I
Page 2 of 3
HI
IV.A.Hasthere been a change in ownershipor control within the last year?
If yes, give date.
B.Do you anticipate anychangeof ownership or control within the year?.
If yes,when?.
C.Do you anticipate filing for bankruptcy within the year?.
If yes,when?
V.Is the facility operated by a management company or leased in whole or part by another organization?..
If yes, give date of change in operations.
VI.Has there been a change in Administrator,Director of Nursing,or Medical Director within the last year?.
VII.A.Is this facility chain affiliated?
(Ifyes, listname,address of corporation, and EIN.
Name
Address (number,name)City
EIN
B.If theanswerto question VILA,is NO,was the facility ever affiliated with a chain?
(If yes,list name,address of corporation,and EIN.)
Address (number,name)City
Exhibit I
Page 3 of 3
YES NO
a a
a a
a 3
3 3
3 3
3 3
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)
Signature
Remarks
r*
Exhibit J
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 ofa 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 toenter into this transaction.However,
failure of the prospective primary participant to furnish a certification oran explanation
shall disqualify such person from participation in thistransaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department oragency determined to enter into this
transaction.If itis later determined that the prospective primaryparticipant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government,the department or agency mayterminatethistransaction 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 inthe Definitions and Coverage
sections ofthe rules implementing Executive Order 12549.You maycontactthe
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 ofa participant is not required toexceedthat
which is normally possessed by a prudent person in the ordinary courseof business
dealings.
m
CERTIFICATION
Exhibit J
2 of 2
(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 ora criminal
offense in connection with obtaining,attemptingto 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 oneor 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)
IDO
Exhibit K
Page 1of 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.Aself-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 purposesof completing this disclosure form.
INSTRUCTIONS
(1)Enter board member's name,job title (if applicable),and date this disclosure is being made.
(2)Enter the board member's company/agency name and address.
(3)Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County.At a minimum,include a description ofthe following:
a.The name of the agency/company with which the corporation has the transaction;and
b.The nature ofthe material financial interest in the Corporation's transaction thatthe
board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions ofthe 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).
IO
(1)Company Board Member Information:
Name:Date:
Job Title:
(2)Company/Agency Name and Address:
(3)Disclosure (Please describe the nature ofthe self-dealing transaction you area party to)
Exhibit K
Page 2 of2
(4)Explain why this self-dealing transaction is consistent with the requirements ofCorporations Code 5233 (a)
(5)Authorized Signature
Signature:Date:
l^l