HomeMy WebLinkAboutCentral Star PHF Agt 14-704-2.pdfCOUNTY OF FRESNO
Fresno, CA
-1 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
AMENDMENT II TO AGREEMENT
THIS AMENDMENT, hereinafter referred to as “Amendment II”, is made and entered into
this ____ day of _______________, 2017, by and between the COUNTY OF FRESNO, a Political
Subdivision of the State of California, hereinafter referred to as “COUNTY”, and CENTRAL STAR
BEHAVIORAL HEALTH, INC., a for-profit organization , whose address is 1501 Hughes Way,
Suite 150, Long Beach, CA 90810, hereinafter referred to as “CONTRACTOR” (collectively as the
“parties”).
WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement
No. 14-704, effective January 1, 2015, and COUNTY Amendment No. 14-704-1, effective May 24,
2016, (collectively referred to herein as “Agreement No. 14-704”) whereby CONTRACTOR agreed to
provide inpatient psychiatric services to youth, twelve (12) years of age to eighteen (18) years of age,
who may be admitted on a voluntary or involuntary basis and may include Medi-Cal beneficiaries,
Medicare and Medicare/Medi-Cal beneficiaries, indigent/uninsured consumers, and juvenile inmates
who are referred by COUNTY’S Department of Behavioral Health (DBH), a contract provider with
DBH, hospital emergency room, or other County departments and agencies; and
WHEREAS, the parties desire to amend COUNTY Agreement No. 14-704 and No. 14-704-1,
regarding changes as stated below and restate the Agreement in its entirety.
NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which
is hereby acknowledged, the parties agree to amend the Agreement as follows:
1.That the text of Agreement No. 14-704 at Page Four (4), beginning with Line Fourteen
(14), with the number “4.” and ending on Page Ten (10), Line Twelve (12) with the word “(SED)” be
deleted and the following inserted in its place:
“4. COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with the budget set forth in Revised Exhibit B-1, attached hereto and by
this reference incorporated herein and made part of this Agreement. For the period of April 1, 2015
through June 30, 2016, the COUNTY shall pay CONTRACTOR for operational costs for up to twelve
(12) beds per day to assist in the program development/capacity of the PHF. The COUNTY and
COUNTY OF FRESNO
Fresno, CA
- 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR agree that the CONTRACTOR will actively solicit and contract with other
entities/agencies for bed placement at the PHF at no cost to the COUNTY. CONTRACTOR will
provide the COUNTY, in writing, a list of secured contracts with hospitals, other agencies, and
counties utilizing the PHF. The COUNTY shall pay the CONTRACTOR for up to twelve (12) beds
per day for FY 2014-15 (April 1, 2015 through June 30, 2015) and FY 2015-16 (July 1, 2015 through
June 30, 2016), less any beds purchased and/or utilized and charged to other outside agencies.
A. Maximum Contract Amount
The maximum amount under this Agreement for the Ramp Up period (January 1,
2015 through March 31, 2015) shall not exceed Four Hundred Fifty-One Thousand, One Hundred
Eighty-Nine and No/100 Dollars ($451,189.00) as identified in Revised Exhibit B-1.
1. The maximum amount for the initial operational term (April 1, 2015
through June 30, 2015) shall not exceed Nine Hundred Twenty-One Thousand, Six Hundred Forty-
Eight and No/100 Dollars ($921,648.00). During the initial operating term, the facility will operate at
a twelve (12) bed capacity. COUNTY shall pay CONTRACTOR for operational costs for up to
twelve (12) beds per day, less any beds purchased and/or utilized and charged to other outside
agencies. The COUNTY shall pay CONTRACTOR Eight Hundred Forty-Four and No/100 Dollars
($844.00) for a daily bed rate.
For the initial operational term (April 1, 2015 through June 30, 2015), it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Four
Hundred Thirty-Seven Thousand, Seven Hundred Eighty-Three and No/100 Dollars ($437,783.00) in
Medi-Cal Federal Financial Participation to offset CONTRACTOR’s program costs. It is further
understood that the amount of Mental Health Realignment, Private Insurance, and Uninsured payable
under this Agreement shall not exceed Four Hundred Eight-Three Thousand, Eight Hundred Sixty-
Five and No/100 Dollars ($483,865.00) as set forth in the budget identified in Revised Exhibit B-1.
2. The maximum amount for the second operational term (July 1, 2015
through June 30, 2016) shall not exceed Three Million, Five Hundred Two Thousand, Eight Hundred
Forty and No/100 Dollars ($3,502,840.00). During the second operational term, the facility will
operate at a twelve (12) bed capacity. The COUNTY shall pay the CONTRACTOR for twelve beds
COUNTY OF FRESNO
Fresno, CA
- 3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
per day, less any beds purchased and/or utilized and charged to other outside agencies. COUNTY
shall pay CONTRACTOR a daily bed rate of Seven Hundred Ninety-Seven and 55/100 Dollars
($797.55) for Fresno County clients.
For the second operational term (July 1, 2015 through June 30, 2016), it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One
Million, Five Hundred Seventy-Six Thousand, Two Hundred Seventy-Eight and No/100 Dollars
($1,576,278.00) in Medi-Cal Federal Financial Participation to offset CONTRACTOR’s program
costs. It is further understood that the amount of Mental Health Realignment, Private Insurance, and
Uninsured payable under this Agreement shall not exceed One Million, Nine Hundred Twenty-Six
Thousand, Five Hundred Sixty-Two and No/100 Dollars ($1,926,562.00) as set forth in the budget
identified in Revised Exhibit B-1.
3, The maximum amount for the third operational term (July 1, 2016
through June 30, 2017) shall not exceed Four Million, One Hundred Sixty-One Thousand, Eight
Hundred Eighteen and No/100 Dollars ($4,161,818.00). During the third operational term, the facility
will operate at a sixteen (16) bed capacity. The COUNTY shall pay the CONTRACTOR for twelve
(12) beds per day, less any beds purchased and/or utilized and charged to other outside agencies.
COUNTY shall pay CONTRACTOR a daily bed rate of Eight Hundred Forty-Four and No/Dollars
($844.00) for Fresno County clients. CONTRACTOR shall seek payment, if applicable, for any costs
above the maximum amount stated herein for FY 2016-17, from other outside agencies.
For the third operational term (July 1, 2016 through June 30, 2017), it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One
Million, Eight Hundred Seventy-Two Thousand, Eight Hundred Eighteen and No/100 Dollars
($1,872,818.00) in Medi-Cal Federal Financial Participation to offset CONTRACTOR’s program
costs. It is further understood that the amount of Mental Health Realignment, Private Insurance, and
Uninsured payable under this Agreement shall not exceed Two Million, Two Hundred Eighty-Nine
Thousand, and No/100 Dollars ($2,289,000.00) as set forth in the budget identified in Revised Exhibit
B-1.
///
COUNTY OF FRESNO
Fresno, CA
- 4 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
4. The maximum amount for the fourth operational term (July 1, 2017
through June 30, 2018) shall not exceed Four Million, Two Hundred Eighty Thousand, Four Hundred
Eighty-Six and No/100 Dollars ($4,280,486.00). During the fourth operational term, the facility will
operate at a sixteen (16) bed capacity. COUNTY shall pay CONTRACTOR for operational costs for
up to sixteen (16) beds per day, less any beds purchased and/or utilized and charged to other outside
agencies. The daily bed rate for Fresno County clients shall be Seven Hundred Thirty-Two and
96/100 Dollars ($732.96), during this term.
For the fourth operational term (July 1, 2017 through June 30, 2018), it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One
Million, Three Hundred Six Thousand, Seven Hundred Thirty-Five and No/100 Dollars
($1,306,735.00) in Medi-Cal Federal Financial Participation to offset CONTRACTOR’s program
costs. It is further understood that the amount of Mental Health Realignment, private insurance,
uninsured, and other revenue payable under this Agreement shall not exceed Two Million, Nine
Hundred Seventy-Three Thousand, Seven Hundred Fifty-One and No/100 Dollars ($2,973,751.00) as
set forth in the budget identified in Revised Exhibit B-1.
5. The maximum amount for the fifth operational term (July 1, 2018
through June 30, 2019) shall not exceed Four Million, Four Hundred Two Thousand, One Hundred
Thirty-Four and No/100 Dollars ($4,402,134.00). During the fifth operational term, the facility will
operate at a sixteen (16) bed capacity. COUNTY shall pay CONTRACTOR for operational costs for
up to sixteen (16) beds per day, less any beds purchased and/or utilized and charged to other outside
agencies. The daily bed rate for Fresno County clients shall be Seven Hundred Fifty-Three and 79/100
Dollars ($753.79), during this term.
For the fifth operational term (July 1, 2018 through June 30, 2019), it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One
Million, Three Hundred Forty-Two Thousand, Six Hundred Fifty and No/100 Dollars ($1,342,650.00)
in Medi-Cal Federal Financial Participation to offset CONTRACTOR’s program costs. It is further
understood that the amount of Mental Health Realignment, private insurance, uninsured, and other
revenue payable under this Agreement shall not exceed Three Million, Fifty-Nine Thousand, Four
COUNTY OF FRESNO
Fresno, CA
- 5 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Hundred Eighty-Four and No/100 Dollars ($3,059,484.00) as set forth in the budget identified in
Revised Exhibit B-1.
6. The maximum contract amount for the sixth operational term (July 1,
2019 through June 30, 2020) shall not exceed Four Million, Five Hundred Thirty-Nine Thousand,
Nine Hundred Eighty-One and No/100 Dollars ($4,539,981.00). During the sixth operational term, the
facility will operate at a sixteen (16) bed capacity. COUNTY shall pay CONTRACTOR for
operational costs for up to sixteen (16) beds per day, less any beds purchased and/or utilized and
charged to other outside agencies. The daily bed rate for Fresno County clients shall be Seven
Hundred Seventy-Five and 27/100 Dollars ($775.27), during this term.
For the sixth operational term (July 1, 2019 through June 30, 2020), it is
understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One
Million, Three Hundred Eighty-Four Thousand, Six Hundred Ninety-Four and No/100 Dollars
($1,384,694.00) in Medi-Cal Federal Financial Participation to offset CONTRACTOR’s program
costs. It is further understood that the amount of Mental Health Realignment, private insurance,
uninsured, and other revenue payable under this Agreement shall not exceed Three Million, One
Hundred Fifty-Five Thousand, Two Hundred Eighty-Seven and No/100 Dollars ($3,155,287.00) as set
forth in the budget identified in Revised Exhibit B-1.
7. In no event shall the total maximum compensation for actual services
performed under this Agreement be in excess of Twenty-Two Million, Two Hundred Sixty Thousand,
Ninety-Six and No/100 Dollars ($22,260,096.00). It is understood that all expenses incidental to
CONTRACTOR’s performance of services under this Agreement shall be borne by CONTRACTOR.
B. If CONTRACTOR fails to generate the Medi-Cal revenue amounts set forth in
Revised Exhibit B-1, the COUNTY shall not be obligated to pay the difference between the estimated
revenue and the actual revenue generated.
It is further understood by COUNTY and CONTRACTOR that any Medi-Cal
revenue and other reimbursement above the amounts stated herein will be used to directly offset the
COUNTY’s contribution of funds identified in Revised Exhibit B-1. The offset of funds will also be
clearly identified in monthly invoices received from CONTRACTOR as further described in Section
COUNTY OF FRESNO
Fresno, CA
- 6 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Five (5) of this Agreement.
Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the Internal Revenue
Service published rate.
Payment shall be made upon certification or other proof satisfactory to
COUNTY’s DBH that services have actually been performed by CONTRACTOR as specified in this
Agreement.
C. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply
with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
D. Payment shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval
by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payment shall be made
after receipt and verification of actual expenditures incurred by CONTRACTOR in performance of
this Agreement and shall be documented to COUNTY on a monthly basis by the tenth (10th) of the
month following the month of said expenditures. The parties acknowledge that the CONTRACTOR
will be developing the PHF during the time period beginning at the execution of this Agreement
through March 31, 2015 and will be performing hiring, training, and credentialing of staff, configuring
the facility and office space, obtaining site certification from the County Mental Health Plan (Mental
Health Plan), and other administrative tasks associated with launching the PHF.
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month
a detailed general ledger (GL) itemizing costs incurred in the previous month. Failure to submit GL
reports and supporting documentation shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance, as further described in Section Five (5) herein.
E. For the Ramp Up period (January 1, 2015 through March 31, 2015), payments
shall be made by COUNTY to CONTRACTOR in equal installments. COUNTY will pay to
CONTRACTOR on the twentieth (20th) of each month for the services to be provided the following
COUNTY OF FRESNO
Fresno, CA
- 7 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
month in the arrears. CONTRACTOR shall submit to COUNTY by the tenth (10th) of the each month
a detailed general ledger (GL) itemizing cost incurred in the previous month. Each payment will be
reconciled to CONTRACTOR’s GL, and any amounts identified as owed to COUNTY will be reduced
from COUNTY’s next payment to CONTRACTOR. The first reconciliation shall be performed after
the third month of the facility’s operation with subsequent reconciliation performed every month
thereafter. The parties agree that the CONTRACTOR shall have the PHF facility operational
commencing April 1, 2015. Failure to submit GL reports and supporting documentation shall be
deemed sufficient cause for COUNTY to withhold payments until there is compliance, as further
described in Section Five (5) herein.
F. For the operational period (April 1, 2015 through June 30, 2015), COUNTY
agrees to pay CONTRACTOR and CONTRACTOR agrees to receive compensation based upon actual
expenditures incurred by CONTRACTOR for monthly program costs, in accordance with the budget
identified in Revised Exhibit B-1.
For the operational period (July 1, 2017 through June 30, 2018) and every twelve
(12) month operational period following, COUNTY agrees to pay CONTRACTOR and
CONTRACTOR agrees to receive compensation based upon actual expenditures incurred by
CONTRACTOR for monthly program costs, in accordance with the budget identified in Revised
Exhibit B-1.
G. Except as provided below regarding State payment delays, payments by
COUNTY shall be in arrears, for services provided during the preceding month, within forty-five (45)
days after receipt, verification, and approval of CONTRACTOR’s invoices by COUNTY’s DBH. If
CONTRACTOR should fail to comply with any provisions of this Agreement, COUNTY shall be
relieved of its obligation for further compensation. All final claims and/or any final budget
modification request shall be submitted by CONTRACTOR within sixty (60) days following the final
month of service for which payment is claimed. No action shall be taken by COUNTY on claims
submitted beyond the sixty (60) day closeout period. Any compensation which is not expended by
CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
COUNTY.
COUNTY OF FRESNO
Fresno, CA
- 8 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
The services provided by CONTRACTOR under Agreement are funded in whole or in
part by the State of California. In the even that funding for these services is delayed by the State
Controller, COUNTY may defer payment to CONTRACTOR. The amount of the deferred payment
shall not exceed the amount of funding delayed by the State Controller to COUNTY. The period of
time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s delay of
payment to COUNTY plus forty-five (45) days.
CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR’s deficiency discovered through the State audit
process and COUNTY utilization review during the course of the agreement. At COUNTY’s election,
the disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or
shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not reiceve
reimbursement for any units of services rendered that are disallowed or denied by the COUNTY
Quality Improvement Committee utilization review process or through State Department of Health
Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients.
H. It is understood by CONTRACTOR and COUNTY that this Agreement is
funded with mental health funds to service individuals with serious emotional disturbances (SED).”
2. That the text of Agreement No. 14-704 at Page Ten (10), beginning with Line Thirteen
(13), with the word number “5.” and ending on Page Fourteen (14), Line Seventeen (17) with the word
“requirements” be deleted and the following inserted in its place:
“5. INVOICING
A. COUNTY’s DBH shall invoice CONTRACTOR by the fifth (5th) day of
each month for the prior month’s expenditures for security, janitorial, landscaping, building
maintenance and utilities for the PHF. CONTRACTOR shall provide payment for these expenditures
to County of Fresno, Department of Behavioral Health, Accounts Receivable, P.O. Box 712, Fresno,
CA 93717-0712, Attention: Business Office, within forty-five (45) days after the date of receipt by
CONTRACTOR of the monthly invoicing provided by COUNTY.
B. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day
of each month for the prior month’s services rendered to DBHInvoices@co.fresno.ca.us. After
COUNTY OF FRESNO
Fresno, CA
- 9 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for
payment, certify the expenditure, and submit electronic claiming billing directly into COUNTY’s
electronic information system for all clients, including those eligible for Medi-Cal as well as those that
are not eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. COUNTY
must pay CONTRACTOR before submitting a claim to the State Department of Health Care Services
(DHCS) for Federal and State reimbursement for Medi-Cal eligible clients.
C. At the discretion of COUNTY’s DBH Director, or designee, if an invoice
is incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director, or designee
shall have the right to withhold payment as to only that portion of the invoice that is incorrect or
improper after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to
provide services for a period of ninety (90) days after notification of an incorrect or improper invoice.
If after the ninety (90) day period, the invoice(s) is still not corrected to COUNTY’s DBH satisfaction,
COUNTY’s DBH Director, or designee, may elect to terminate this Agreement, pursuant to the
termination provisions stated in Section Three (3) of this Agreement. In addition, for invoices
received ninety (90) days after the expiration of each term of this Agreement or termination of this
Agreement, at the discretion of COUNTY’s DBH Director, or designee, COUNTY’s DBH shall have
the right to deny payment of any additional invoices received.
D. Initial invoice for ramp up period (January 1, 2015 to March 31, 2015)
will not contain roster reporting. Monthly invoices during the operational period (after March 31,
2015) shall include a client roster identifying bed utilization unit/bed volume reported by payer group
for clients served (including clients from other agencies and third party payer of services) by month
and year-to-date. For the initial fifteen months of the operational contract (April 1, 2015 to June 30,
2016) the CONTRACTOR’s client roster reporting will contain the twelve (12) bed funding
calculation as stated in Section Four (4) above.
E. CONTRACTOR shall submit monthly invoices and general ledgers that
itemize the line item charges for monthly program costs (per applicable budget, as identified in
Revised Exhibit B-1), including the cost per unit calculation based on clients served within that month,
and excluding unallowable costs. Unallowable costs such as lobbying or political donations must be
COUNTY OF FRESNO
Fresno, CA
- 10 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
deducted from the monthly invoice reimbursements. The invoices and general ledgers will serve as
tracking tools to determine if CONTRACTOR’s program costs are in accordance with its budgeted
cost compared to actual cost per unit, as set forth in Revised Exhibit B-1. The actual cost per unit will
be based upon total costs and total units of service. It will also serve for the COUNTY to certify the
public funds expended for purposes of claiming federal reimbursement for the cost of Medi-Cal
services and activities. CONTRACTOR shall remit to COUNTY on a quarterly basis, a summary
report of total operational costs and volume of service units to report the actual costs per unit
compared to the negotiated rate, as identified in Revised Exhibit B-1, to report the interim cost per
unit. The quarterly reports will be used by COUNTY to ensure compliance with Federal and State
reimbursements certified public expenditures.
F. CONTRACTOR will remit annually within ninety (90) days from June
30, a schedule to provide the required information on published charges for all authorized services.
The published charge listing will serve as a source document to determine the CONTRACTOR’s
usual and customary charge prevalent in the public mental health sector that is used to bill the general
public, insurers, or other non-Medi-Cal third party payers during the course of business operations.
G. CONTRACTOR shall submit monthly staffing report that identify all
direct service and support staff, applicable licensure/certification, and full-time hours worked to be
used as a tracking tool to determine if CONTRACTOR’s program is staffed according to the services
provided under this Agreement.
H. CONTRACTOR must maintain such financial records for a period of
seven (7) years or until any dispute, audit, or inspection is resolved, whichever is later.
CONTRACTOR will be responsible for any disallowances related to inadequate documentation.
I. CONTRACTOR is responsible for collection and managing data in a
manner to be determined by DHCS and the Mental Health Plan in accordance with applicable rules
and regulations. COUNTY electronic information system is a critical source of information for
purposes of monitoring service volume and obtaining reimbursement. CONTRACTOR must attend
COUNTY DBH’s Business Office training on equipment reporting for assets, intangible and sensitive
minor assets, COUNTY’s electronic information system, and related cost reporting.
COUNTY OF FRESNO
Fresno, CA
- 11 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
J. CONTRACTOR shall submit service data into COUNTY’s electronic
information system within thirty (30) calendar days from the date services were rendered. Federal and
State reimbursement for Medi-Cal specialty mental health services is based on public expenditures
certified by the CONTRACTOR. CONTRACTOR must submit a signed certified public expenditure
report with each respective monthly invoice. DHCS expects the claim for reimbursement to equal the
amount the COUNTY paid the CONTRACTOR for the service rendered less any funding sources not
eligible for Federal and State reimbursement.
K. CONTRACTOR must provide all necessary data to allow the COUNTY
to bill Medi-Cal, and any other third-part source, for services and meet State and Federal reporting
requirements. The necessary data can be provided by a variety of means, including but not limited to:
1) direct data entry into COUNTY’s electronic information system; 2) providing an electronic file
compatible with COUNTY’s electronic information system; or 3) integration between COUNTY’s
electronic information system and CONTRACTOR’s information system(s).
L. If a client has other health coverage (OHC) such as private insurance, or
Federal Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a
payment/denial, or have validation of claiming with no response ninety (90) days after the claim was
mailed, before the service can be entered into the COUNTY’s electronic information system. A copy
of explanation of benefits or CMS 1500 is required as documentation. CONTRACTOR must report
all revenue collection from OHC, third party, client-pay, or private-pay in each monthly invoice and in
the cost report that is required to be submitted. CONTRACTOR shall submit monthly invoices for
reimbursement that equal the amount due CONTRACTOR less any funding sources not eligible for
Federal and State reimbursement. CONTRACTOR must comply with all laws and regulations
governing the Federal Medicare program, including, but not limited to 1) the requirement of the
Medicare Act, 42 U.S.C. section 1395 et seq; and 2) the regulation and rules promulgated by the
Centers for Medicare and Medicaid Services as they relate to participation, coverage, and claiming
reimbursement. CONTRACTOR will be responsible for compliance as of the effective date of each
Federal, State, or local law or regulation specified.
///
COUNTY OF FRESNO
Fresno, CA
- 12 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
M. Data entry shall be the responsibility of the CONTRACTOR. The direct
specialty mental health services data must be reconciled by the CONTRACTOR to the monthly
invoices submitted for payment. COUNTY shall monitor the number the volume of services and cost
of services entered into the COUNTY’s electronic information system. Any and all audit exceptions
resulting from the provision and billing of Medi-Cal services by CONTRACTOR shall be the sole
responsibility of the CONTRACTOR. CONTRACTOR will comply with all applicable policies,
procedures, directives, and guidelines regarding the use of COUNTY’s electronic information system.
N. Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR will establish and maintain Medi-Cal certification or
become certified within ninety (90) days of the effective date of this Agreement through COUNTY to
provide reimbursable services to Medi-Cal eligible clients. In addition, CONTRACTOR shall work
with the COUNTY’s DBH to execute the process if not currently certified by COUNTY for
credentialing of staff. During this process, the CONTRACTOR will obtain a legal entity number
established by the DHCS, as this is a requirement for maintaining Mental Health Plan organizational
provider status throughout the term of this Agreement. CONTRACTOR will be required to become
Medi-Cal certified prior to providing services to Medi-Cal eligible clients and seeking reimbursement
from the COUNTY. CONTRACTOR will not be reimbursed by COUNTY for any services rendered
prior to certification.
CONTRACTOR shall provide specialty mental health services in
accordance with the COUNTY’s Mental Health Plan. CONTRACTOR must comply with the “Fresno
County Mental Health Plan Compliance Program and Code of Conduct” set forth in Exhibit C,
attached hereto and by this reference incorporated herein and made part of this Agreement.
CONTRACTOR may provide direct specialty mental health services
using unlicensed staff as long as the individual is approved as a provider by the Mental Health Plan, is
supervised by licensed staff, works within his/her scope, and only delivers allowable 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 service is disapproved, COUNTY may, at its sole discretion, withhold compensation or set
COUNTY OF FRESNO
Fresno, CA
- 13 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
off from other payments due the amount of said disapproved services. CONTRACTOR shall be
responsible for audit exceptions to ineligible dates of services or incorrect application of utilization
review requirements.”
3. That all references in Agreement No. 14-704 to “Exhibit A” shall be changed to read
“Revised Exhibit A,” attached hereto and incorporated herein by reference.
4. That all references in Agreement No. 14-704 to “Revised Exhibit B” shall be changed
to read “Revised Exhibit B-1,” attached hereto and incorporated herein by reference.
5. COUNTY and CONTRACTOR agree that this Amendment II is sufficient to amend the
Agreement; and that upon execution of this Amendment II, the Agreement, Amendment I, and
Amendment II together shall be considered the Agreement.
The Agreement, as hereby amended, is ratified and continued. All provisions, terms,
covenants, conditions and promises contained in the Agreement, and not amended herein, shall remain
in full force and effect. This Amendment II shall become effective upon execution by all parties.
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
1
2
3
4
5
6
7
8
9
10
IN WITNESS WHEREOF the parties hereto have executed this Amendment II to COUNTY
Agreement No . 14-704 as of the day and year first hereinabove w ritten.
CONTRACTOR:
CENTRAL STAR BEHAVIORAL
HEALTH INC.
By L¥~~
PrintName : ~L~n+ 4?. <r ~ __,--
Title: f'/e'p£t4_/:~ {A_o
Chairman of Board , or
COUNTY OF FRESNO
(lll_
By ________ ~~------------
Chairman, Board of Supervisors
Date: Lp -d--0 - \ J
11 President, or any Vice President
1 2
1 3
14
15
16
17
1 8
19
20
21
22
23
24
25
26
27
28
By &~
Print Name: 7 t:lnA-nJoy-gr.n
Title: S-c.crz..e P ~
Secretary (of Corp t10n ), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Mailing Address:
Central Star Behavioral Health Inc .
1501 Hughes Way, Suite 150
Long Beach , CA 9081 0
Contact: Senior Vice President
Phone: (31 0) 221-6336 ext 125
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-14 -COUN TY OF FRESNO
Fresno, Cl'l
Revised Exhibit A
Page 1 of 7
YOUTH ACUTE INPATIENT PSYCHIATRIC SERVICES
Psychiatric Health Facility (PHF)
Scope of Work
ORGANIZATION: Central Star Behavioral Health, Inc.
ADDRESS: 1501 Hughes Way, Suite 150, Long Beach, CA 90810
SITE ADDRESS: 4411 E. Kings Canyon Road, Fresno, CA, 93702
SERVICES: Psychiatric Health Facility
PROJECT DIRECTOR: Kent Dunlap, Senior Vice President
Phone Number: (310) 221-6336 ext. 125
CONTRACT PERIOD: January 1, 2015 - March 31, 2015 (ramp up period)
April 1, 2015 – June 30, 2015 with an option for five (5) twelve (12) month
renewals (operational period)
CONTRACT AMOUNT: $ 451,189 1/1/2015 through 3/31/2015 (ramp up period)
$ 921,648 4/1/2015 through 6/30/2015 (initial operational period)
$3,502,840 FY 2015-16
$4,161,818 FY 2016-17
$4,280,486 FY 2017-18
$4,402,134 FY 2018-19
$4,539,981 FY 2019-20
SCHEDULE OF SERVICES:
CONTRACTOR shall operate the youth Psychiatric Health Facility (PHF) 24 hours per day, seven (7) days per
week. The PHF shall be located at 4411 E. Kings Canyon Road, Fresno, CA 93702, a COUNTY owned
building, pursuant to a separate lease agreement between COUNTY and CONTRACTOR.
TARGET POPULATION:
The target population will include youth twelve (12) years of age up to 18 years of age, who may be admitted
on a voluntary or involuntary basis. These clients will include Medi-Cal beneficiaries, Medicare and
Medicare/Medi-Cal beneficiaries, and indigent/uninsured clients who are referred by the Department of
Behavioral Health (DBH) and other County Departments, a contract provider with the DBH, a hospital
emergency room (aka emergency department), Juvenile Hall, and other agencies.
PROJECT DESCRIPTION:
CONTRACTOR will implement a youth Psychiatric Health Facility (PHF) to serve 684 (57/month) clients for
each 12 month period of this agreement. Services include intensive, acute care, trauma-informed residential
treatment to youth twelve (12) years of age up to 18 years of age. CONTRACTOR will provide 12 beds for the
initial fifteen (15) months of operation (April 1, 2015 through June 30, 2016). In Fiscal Year 2016-17, and each
subsequent year, CONTRACTOR will provide for 16 beds at any given time. Fresno County Department of
Behavioral Health will have a designated amount of dedicated beds as stated in Paragraph 4 of the
Agreement. Program goal of the PHF is to provide acute psychiatric hospitalization, coordinated discharge
planning and effective linkages to post-hospital outpatient mental health treatment programs and other
supportive services for youth and their families.
Revised Exhibit A
Page 2 of 7
CONTRACTOR shall be responsible to comply with the requirements of the Fresno County Mental Health Plan
(FCMHP) and must complete and submit supporting documentation for all admissions regardless of payer
source to the Fresno County Mental Health Plan (FCMHP). The FCMHP will perform a utilization review of all
Medi-Cal beneficiaries to determine that the documentation demonstrates that medical necessity criteria, as
defined by the California Department of Health Care Services. The 16 bed facility will be licensed by the State
of California, Department of Health Care Services (DHCS), and meet all regulations required for operating a
psychiatric health facility W&I Code 4080 Article 3; Health and Safety Code 1250.2 and meet Medi-Cal
certification by the County.
CONTRACTOR shall be responsible to enter all Client Service Information, admission data and billing
information into the County data system (AVATAR) and will be responsible for any and all audit exceptions
pertaining to the delivery of services. The CONTRACTOR will also be responsible for the mandated reporting
of patient information and admission/discharge data and other required reports to the Office of State Health
Planning and Development (OSHPD), the California Department of Health Care Services, and meet the
submission deadlines on June 30 and December 31 each calendar year.
CONTRACTOR’S RESPONSIBILITIES:
A. GOALS:
1. Management and alleviation of client’s acute psychiatric symptoms to prevent clients from
requiring inpatient services and use a less restrictive level of care.
2. Clinical program recovery/strength based with appropriate professional staffing on a 24 hour, 7
day a week basis.
3. Safe, secure and structured environment that promotes the clients wellness and recovery,
including connections to family and community.
4. Comprehensive multi-disciplinary evaluation and client-centered care plan for each client.
5. Dietary services through the availability of nourishment or snacks in accordance with Title 22,
Division 5, Chapter 9, Article 3, Section 77077. A dietician will be utilized for menu planning and
assessment for dietary special needs, consistent with Title 22 requirements.
6. Admission procedures will be in place for voluntary and involuntary clients.
7. Treatment Planning – The Psychiatric Health Facility staff will provide the following services
captured in written assessment and care plans:
a. Mental Status Examination
b. Medical Evaluation
c. Psycho-Social Assessment
d. Nursing Assessment
e. Multi-Disciplinary Milieu Treatment Program
f. Individualized Focused Treatment Planning
g. Aftercare Planning
8. Staffing
a. The staffing pattern and all staff working at the PHF shall meet all State licensing and
regulatory requirements including medical staff standards, nursing staff standards, social
work and rehabilitation staff requirements pursuant to Title 9, Division 1, Chapter 11,
Revised Exhibit A
Page 3 of 7
Article 3, Section 1840.348 of the California Code of Regulations for Psychiatric Health
Facilities All staff, which requires state licensure or certification, will be required to be
licensed or certified in the State of California and be in good standing with the state
licensing or certification board.
b. All facility staff, who provide direct patient care or perform coding/billing functions, must
meet the requirements of the FCMHP Compliance Program. This includes the screening
for excluded persons and entities by accessing or querying the applicable licensing
board(s), the National Practitioner Data Bank (NPDB), Office of Inspector General’s List of
Excluded Individuals/Entities (LEIE), Excluded Parties List System (EPLS) and Medi-Cal
Suspended and Ineligible List prior to hire and monthly thereafter. In addition, all
licensed/registered/waivered staff must complete a FCMHP Provider Application and be
credentialed by the FCMHP’s Credentialing Committee. All licensed staff shall have
Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Sheriff
fingerprinting (Lives can) executed.
c. Peer and/or Family Support staff will help to educate, support and advocate on behalf of
children, youth and their families during the hospitalization and will assist with discharge
planning and the transition to follow-up care.
9. Medical Records and Mandated Reporting:
a. The CONTRACTOR shall be responsible to enter all Client Service Information, admission
data and billing information into the County data system (AVATAR) and will be responsible
for any and all audit exceptions pertaining to the delivery of services.
b. The CONTRACTOR will be responsible for “release of information” requests f or the PHF
and shall adhere to applicable federal and state regulations.
c. The CONTRACTOR will report information and admission/discharge data to the Office of
Statewide Health Planning and Development and meet the submission deadlines of June
30 and December 31 each calendar year.
10. Organized Clinical Staff - clinical staff will be licensed mental health professionals as well as
Rehabilitation Therapists with appropriate education, credentialing and experience to reach
status as a Qualified Mental Health Professional (QMHP).
11. Pharmaceutical and Medication Services – controls traditional to PHF’s for pharmaceutical and
medication services will be reflected. CONTRACTOR will have policies, procedures and
physician/nursing protocols in place regarding medication labeling, storage/security, orders, use
of med carts, administration, polypharmacy, and monitoring response will observed.
12. Physical Health Care – CONTRACTOR will contract with a primary care physician and a
registered dietician. CONTRACTOR will provide a full health history upon admission.
CONTRACTOR will have a written agreement with one or more acute care hospitals to provide
services for youth requiring additional needed services.
13. Schedule of Active Therapies - CONTRACTOR shall provide a daily schedule of therapeutic
activities that will be provided as part of the clinical treatment program. The schedule shall
include wellness education with motivational support, psycho-social and life skill building groups
on varied topics, family therapy, creative expressive arts, recreational and fitness programs. The
treatment team is expected to schedule clients participation activities tailored to each client’s
individual needs. There will also be daily meetings among the staff and youth for general
education and guidance about unit activities and to collectively address milieu living issues.
14. Utilization Review, Billing and Cost Report:
Revised Exhibit A
Page 4 of 7
a. CONTRACTOR shall notify the Department of any admission of a County client within 24
hours or the next business day in a manner approved by the County. The notification
method shall be mutually acceptable by both County and CONTRACTOR.
b. CONTRACTOR shall be responsible to insure that documentation in the client’s medical
record meets medical necessity criteria for the hours of service submitted to County for
reimbursement by federal intermediaries, third-party payers and other responsible parties.
c. CONTRACTOR shall enter all mental health data and billing information into the County
data system and will be responsible for any and all audit exceptions pertaining to the
delivery of services. For Medi-Cal billing denials by the State, CONTRACTOR will
maintain an error rate no greater than five percent (5%).
d. CONTRACTOR shall submit a complete and accurate State of California Department of
Health Care Services Short (DHCS)/Doyle Medi-Cal Cost Report for each fiscal year
ending June 30th affected by the proposed agreement within 90 days following the end of
each fiscal year.
e. CONTRACTOR shall insure that cost reports are prepared in accordance with general
accounting principles and the standards set forth by the DHCS and the County.
15. Patients Rights and Certification Review Hearings
a. CONTRACTOR shall adopt and post in a conspicuous place a written policy on patient
rights in accordance with section 70707 of Title 22 of the California Code of Regulations
and section 5325.1 of the California Welfare and Institutions Code and Title 42 Code of
Federal Regulations section 438.100.
b. CONTRACTOR shall allow access to County clients by the Patients’ Rights Advocate
designated by the County.
c. CONTRACTOR shall conduct Mental Health Certification Review Hearings in accordance
with regulations in a location within the facility that allows for confidentiality and is
compatible with and is least disruptive to the treatment being provided to the County
patient.
16. Grievances and Incident Reports - CONTRACTOR shall log all grievances and the disposition of
all grievances received from a client or a client’s family in accordance with Fresno County Mental
Health Plan policies and procedures as indicated within Exhibit H. CONTRACTOR shall provide
a summary of the grievance log entries concerning County-sponsored clients to the Department
of Behavioral Health Director or designee at monthly intervals, by the fifteenth (15th) day of the
following month, in a format that is mutually agreed upon. CONTRACTOR shall post signs,
provided by the County, informing clients of their right to file a grievance and appeal.
CONTRACTOR shall notify County of all incidents or unusual occurrences reportable to state
licensing bodies that affect County clients within twenty-four (24) hours. The CONTRACTOR
shall use the Incident Report form as indicated within Exhibit I for such reporting.
Within fifteen (15) days after each grievance or incident affecting County-sponsored clients,
CONTRACTOR shall provide County with the complaint and CONTRACTOR’S disposition of, or
corrective action taken to resolve the complaint or incident.
Within fifteen (15) days after CONTRACTOR submits a corrective action plan to a California State
licensing and/or accrediting body concerning any sentinel event, as the term is defined by the
licensing or accrediting agency, and within fifteen (15) days after CONTRACTOR receives a
corrective action order from a California State licensing and/or accrediting body to address a
sentinel event, CONTRACTOR shall provide a summary of such plans and orders to County.
Revised Exhibit A
Page 5 of 7
B. OBJECTIVES
1. Safe and Secure Environment - to provide for clinical and medical assessment, diagnostic
formulation, crisis intervention, medication management and clinical treatment for mental
health clients with acute psychiatric disorder. All client care staff will be trained and certified
by a nationally recognized assault crisis training that is principally focused on crisis prevention
and de-escalation.
2. Provide the appropriate type and level of staffing to provide for a clinical effective program
design.
3. Provide an intensive treatment program which has individualized client care plans.
4. Stabilize consumers as soon as possible in order to assist them in their recovery from mental
illness.
5. Effectively partner with other programs in the Crisis Intervention Redesign in accepting
County consumers for admission for acute inpatient psychiatric services and also to work
collaboratively in discharge planning to insure appropriate ongoing outpatient specialty mental
health treatment services are provided.
6. Identify County consumers with frequent admissions during the fiscal year and to develop
strategies with other County and community agencies to reduce readmissions.
7. Effectively interact with community agencies, other mental health programs and providers,
natural support systems and families to assist consumers to be discharged to the more
appropriate level of care.
8. Integrate mental health and substance abuse services through comprehensive continuous
integrated systems of care for the life span of those served and to work as partners with a
shared vision: to create a coordinated and comprehensive system of service delivery. The
CONTRACTOR shall perform the following:
a. Demonstrate familiarity with the County Comprehensive Continuation Integrated System of
Care (CCISC) consensus document and with the process of CCISC implementation, both
in terms of county level activities, as well as the continuous quality improvement process
that each program organizes in order to make progress toward co-occurring disorder
capability.
b. Conduct an on going agency self survey using the COMPASSTM (Co-Morbidity Program
Audit and Self-Survey for behavioral health services), using the recommended focus group
process to engage staff of all levels in the conversation.
c. Identify a Change Agent to represent the program, and support that Change Agent to
participate actively in the County change agent team. The role of the change agent is to
provide training and supervision in accordance with the principles of the Comprehensive
Continuous Integrated Systems of Care model in order to establish and enhance dual
diagnosis competency in program staff and to provide consultation to facilitate
development and implementation of quality improvement action planning to establish and
enhance dual diagnosis capability in the program as a whole.
d. Develop a formal written Continuous Quality Improvement (CQI) action plan to identify
measurable objectives toward the achievement of Co-Occurring Disorders (COD)
capability that will be addressed by the program during the contract period. These
objectives should be ACHIEVABLE and REALISTIC for the program, based on the self
assessment and the program priorities, but need to include attention to making progress
on the following issues, at minimum (as outlined in the Charter):
Revised Exhibit A
Page 6 of 7
1. Welcoming policies, practices, and procedures related to the engagement of
individuals with co-occurring issues and disorders;
2. Removal or reduction of access barriers to admission based on co-occurring
diagnosis or medication;
3. Improvement in routine integrated screening, and identification in the data
system of how many clients served have co-occurring issues;
4. Developing the goal of basic co-occurring competency for all treatment staff,
regardless of licensure or certification, and
5. Documentation of coordination of care with collaborative mental health and/or
substance abuse providers for each client.
C. Regarding cultural and linguistic competence requirements:
1. CONTRACTOR shall provide services as stated in section 29 of the Agreement.
D. Regarding direct admissions to the PHF from COUNTY DBH programs or its contracted
providers, the CONTRACTOR agrees to the following:
1. To allow direct admits from COUNTY DBH programs or its contracted providers when PHF
beds are available.
2. Said direct admits shall not require medical clearance. However, in the event a referred client
is known to possess a contagious medical condition, said patient shall be medically cleared by
a local hospital prior to admission to the PHF operated by CONTRACTOR.
E Regarding the provision of court testimony related to PHF patients, CONTRACTOR
agrees to the following:
1. CONTRACTOR’S appropriate staff shall provide court testimony relevant to PHF clients when
required.
COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Perform a utilization review (through its FCMHP) of all Medi-Cal beneficiaries to determine that the
documentation demonstrates that medical necessity criteria as defined by the California Department of
Health Care Services (DHCS) was met for each period of the admission, except for the episode of
discharge.
2. Provide oversight (through the County Department of Behavioral Health (DBH), Children’s Mental Health
Division Manager or designee) of the CONTRACTOR’S PHF program. In addition to contract monitoring
of program(s), oversight includes, but not limited to, coordination with the State Department of Health
Care Services in regard to program administration and outcomes.
3. Assist the CONTRACTOR in making linkages with the total mental health system. This will be
accomplished through regularly scheduled meetings as well as formal and informal consultation.
4. Participate in evaluating the progress of the overall program and the efficiency of collaboration with the
CONTRACTOR staff and will be available to the contractor for ongoing consultation.
5. Receive and analyze statistical outcome data from CONTRACTOR throughout the term of contract on a
monthly basis. DBH will notify the CONTRACTOR when additional participation is required. The
Revised Exhibit A
Page 7 of 7
performance outcome measurement process will not be limited to survey instruments but will also
include, as appropriate, client and staff interviews, chart reviews, and other methods of obtaining
required information.
6. Recognize that cultural competence is a goal toward which professionals, agencies, and systems should
strive. Becoming culturally competent is a developmental process and incorporates at all levels the
importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that
result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to
meet culturally-unique needs. Offering those services in a manner that fails to achieve its intended
result due to cultural and linguistic barriers is not cost effective. To assist the CONTRACTOR’S efforts
towards cultural and linguistic competency, DBH shall provide the following at no cost to
CONTRACTOR:
A. Technical assistance to CONTRACTOR regarding cultural competency requirements and sexual
orientation training.
B. Mandatory cultural competency training including sexual orientation and sensitivity training for
CONTRACTOR personnel, at minimum once per year. County will provide mandatory training
regarding the special needs of this diverse population and will be included in the cultural
competence training(s). Sexual orientation and sensitivity to gender differences is a basic cultural
competence principle and shall be included in the cultural competency training. Literature suggests
that the mental health needs of lesbian, gay, bisexual, transgender (LGBT) individuals may be at
increased risk for mental disorders and mental health problems due to exposure to societal
stressors such as stigmatization, prejudice and anti-gay violence. Social support may be critical for
this population. Access to care may be limited due to concerns about providers’ sensitivity to
differences in sexual orientation.
C. Technical assistance for CONTRACTOR in translating behavioral health and substance abuse
services information into DBH’s threshold languages (Spanish, Laotian, Cambodian and Hmong).
Translation services and costs associated will be the responsibility of the CONTRACTOR.
Revised Exhibit B-1
Page:1 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $0 $16,640 $16,640
0002 RN 3.20 $0 $10,677 $10,677
0003 LVN 2.80 $0 $5,096 $5,096
0004 Rehab Therapist 1.40 $0 $2,548 $2,548
0005 Rehab Aide 3.00 $0 $3,500 $3,500
0006 Youth Counselor 16.80 $0 $20,952 $20,952
0007 Admissions Coordinator 1.00 $0 $2,427 $2,427
0008 Family Advocate 1.00 $0 $1,400 $1,400
0009 Social Workers 2.80 $0 $7,159 $7,159
0010 Program Director 1.00 $0 $10,400 $10,400
0011 Cook 2.10 $0 $2,452 $2,452
0012 Administrator 0.75 $22,246 $0 $22,246
0013 HR Manager 0.50 $7,353 $0 $7,353
0014 QA Medical Records 0.50 $1,083 $0 $1,083
0015 Training Coordinator 0.50 $1,065 $0 $1,065
0016 Billing Clerk 1.00 $953 $0 $953
0017 Maintenance Tech 1.00 $1,333 $0 $1,333
0018 Housekeeper 1.50 $1,249 $0 $1,249
SALARY TOTAL 41.85 $35,282 $83,249 $118,532
PAYROLL TAXES:
0030 FICA/MEDICARE $2,699 $6,369 $9,068
0031 SUI $190 $449 $639
0032 FUTA $332 $783 $1,115
PAYROLL TAX TOTAL $3,221 $7,601 $10,822
EMPLOYEE BENEFITS:
0040 Retirement $29 $0 $29
0041 Workers Compensation $1,750 $4,129 $5,879
0042 $1,130 $0 $1,130
EMPLOYEE BENEFITS TOTAL $2,909 $4,129 $7,038
SALARY & BENEFITS GRAND TOTAL $136,392
FACILITIES/EQUIPMENT EXPENSES:
1010 Offsite Lease - Admin/Business Office $1,500
1011 Leased Equipment $1,180
1012 Telecommunications $17,155
1013 Utilities $6,895
1014 Maintenance $1,943
FACILITY/EQUIPMENT TOTAL $28,673
OPERATING EXPENSES:
1060 $1,400
1061 $2,000
1062 $800
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Housekeeping Supplies
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
Start Up Budget - proposed start date through proposed end date (FY 2014-15 - Jan-Mar 2015)
Budget Categories - Total Proposed Budget
Revised Exhibit B-1
Page:2 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
Start Up Budget - proposed start date through proposed end date (FY 2014-15 - Jan-Mar 2015)
1063 $1,000
1064 $0
1065 $7,200
1066 $1,200
1067 $20,000
OPERATING EXPENSES TOTAL $33,600
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $54,872
1081 General Insurance $1,100
1082 Centralized fiscal service .05 $21,484
FINANCIAL SERVICES TOTAL $77,456
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $9,795
1088 Supplies - House Meds $875
1089 Supplies - Medical $541
1090 Supplies Non-Medical $4,587
1091 Medical Records Supplies $300
1092 Food $615
1093 Supplies Non-Perishables $650
1094 Laundry & Linen $1,000
1095 Centralized Services - Program $6,080
SPECIAL EXPENSES TOTAL $24,443
FIXED ASSETS:
2000 Furniture & Fixture $82,414
2001 Security-Access Control System & Cameras $52,561
2002 IT Minor Equipment $15,650
Assets (useful life more than 1 year and valued at more than $5,000)
2003 Intangible software/License Assets (useful life more than 1 year and valued at more than $100,000)$0
FIXED ASSETS TOTAL $150,625
TOTAL PROGRAM EXPENSES $451,189
Recruiting
EMR Cost
Travel
Education & Training
Licenses
Revised Exhibit B-1
Page:3 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
Start Up Budget - proposed start date through proposed end date (FY 2014-15 - Jan-Mar 2015)
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility $0
DIRECT SERVICE REVENUE TOTAL 0 $0
#REF!
Cost Per Unit #DIV/0!
FUNDING STREAMS REIMBURSEMENT
4000 Realignment Funding $451,189.00 $451,189
4100 Other
4200 Other
4300 Other
REVENUE TOTAL $451,189
Medi-cal Revenue
Revised Exhibit B-1
Page:4 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $0 $24,960 $24,960
0002 RN 3.20 $0 $64,064 $64,064
0003 LVN 2.80 $0 $30,576 $30,576
0004 Rehab Therapist 1.40 $0 $15,288 $15,288
0005 Rehab Aide 3.00 $0 $20,998 $20,998
0006 Youth Counselor 16.80 $0 $125,711 $125,711
0007 Admissions Coordinator 1.00 $0 $14,560 $14,560
0008 Family Advocate 1.00 $0 $8,398 $8,398
0009 Social Workers 2.80 $0 $42,952 $42,952
0010 Program Director 1.00 $0 $15,600 $15,600
0011 Cook 2.10 $0 $14,709 $14,709
0012 Administrator 0.75 $22,246 $0 $22,246
0013 HR Manager 0.50 $7,353 $0 $7,353
0014 QA Medical Records 0.50 $6,500 $0 $6,500
0015 Training Coordinator 0.50 $6,391 $0 $6,391
0016 Billing Clerk 1.00 $5,720 $0 $5,720
0017 Maintenance Tech 1.00 $7,998 $0 $7,998
0018 Housekeeper 1.50 $7,496 $0 $7,496
SALARY TOTAL 41.85 $63,703 $377,816 $441,518
PAYROLL TAXES:
0030 FICA/MEDICARE $4,873 $28,903 $33,776
0031 SUI $344 $2,040 $2,384
0032 FUTA $599 $3,551 $4,150
PAYROLL TAX TOTAL $5,816 $34,494 $40,310
EMPLOYEE BENEFITS:
0040 Retirement $2,797 $16,586 $19,383
0041 Workers Compensation $3,160 $18,740 $21,900
0042 $7,294 $43,260 $50,554
EMPLOYEE BENEFITS TOTAL $13,250 $78,586 $91,837
SALARY & BENEFITS GRAND TOTAL $573,665
FACILITIES/EQUIPMENT EXPENSES:
1010 Offsite Lease - Admin/Business Office $1,500
1011 Leased Equipment $1,770
1012 Telecommunications $8,250
1013 Utilities $17,750
1014 Maintenance $1,500
1015 Security-Access Control System & Cameras $0
FACILITY/EQUIPMENT TOTAL $30,770
OPERATING EXPENSES:
1060 $19,751
1061 $500
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (16 Bed) operated at a 12 bed capacity
Central Star Behavioral Health, Inc.
Operational Budget (April 1, 2015 through June 30, 2015)
Budget Categories - Total Proposed Budget
Revised Exhibit B-1
Page:5 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed) operated at a 12 bed capacity
Central Star Behavioral Health, Inc.
Operational Budget (April 1, 2015 through June 30, 2015)
1062 $1,561
1063 $1,561
1064 $0
1065 $450
1066 $3,600
OPERATING EXPENSES TOTAL $27,422
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $86,235
1081 General Insurance $3,305
1082 Centralized fiscal service .05 $43,938
FINANCIAL SERVICES TOTAL $133,478
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $107,990
1088 Contract Therapist $8,286
1089 Supplies - House Meds $2,733
1090 Supplies - Medical $1,689
1091 Supplies Non-Medical $1,000
1092 Medical Records Supplies $165
1093 Food $12,421
1094 Supplies Non-Perishables $438
1096 Laundry & Linen $3,571
1097 Allowance $1,873
1098 Clothing $5,015
1099 Legal Fees $1,248
2000 Employee Benefits Other $765
Centralized Services - Program $9,120
SPECIAL EXPENSES TOTAL $156,314
FIXED ASSETS:
2000 Furniture & Fixture $0
2002 IT Minor Equipment $0
Assets (useful life more than 1 year and valued at more than $5,000)
2003 Intangible software/License Assets (useful life more than 1 year and valued at more than $100,000)$0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $921,649
Recruiting
Travel
Housekeeping Supplies
Education & Training
Licenses
Revised Exhibit B-1
Page:6 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed) operated at a 12 bed capacity
Central Star Behavioral Health, Inc.
Operational Budget (April 1, 2015 through June 30, 2015)
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility 12 beds 1,092 $844.00 $921,648
DIRECT SERVICE REVENUE TOTAL 1,092 $921,648
$875,566
Cost Per Unit $844.00
FUNDING STREAMS REIMBURSEMENT Population Served Percentage
4000 Private Insurance 3%$27,649
4100 Uninsured 2%$18,433
4200 Medi-Cal FFP 95%$437,783
4300 2011 Realignment $437,783
REVENUE TOTAL $921,648
Medi-cal Revenue
Revised Exhibit B-1
Page:7 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $0 $101,464 $101,464
0002 RN 3.20 $0 $260,425 $260,425
0003 LVN 2.80 $0 $124,294 $124,294
0004 Rehab Therapist 1.40 $0 $62,147 $62,147
0005 Rehab Aide 1.40 $0 $39,833 $39,833
0006 Youth Counselor 15.40 $0 $468,439 $468,439
0008 Family Advocate 1.00 $0 $34,138 $34,138
0009 Social Workers 2.80 $0 $174,603 $174,603
0010 Program Director 1.00 $0 $63,415 $63,415
0011 Cook 2.10 $0 $59,794 $59,794
0012 Administrator 0.75 $111,946 $0 $111,946
0013 UR/QA/Medical Records 1.00 $58,203 $0 $58,203
0014 HR/Training/Admin Asst 1.00 $66,470 $0 $66,470
0015 Billing Clerk 1.00 $23,252 $0 $23,252
0016 Maintenance Tech 0.50 $16,255 $0 $16,255
0017 Housekeeper 1.90 $38,597 $0 $38,597
SALARY TOTAL 38.25 $314,723 $1,388,552 $1,703,275
PAYROLL TAXES:
0030 FICA/MEDICARE $24,076 $106,225 $130,301
0031 SUI $1,699 $7,497 $9,196
0032 FUTA $2,958 $13,053 $16,011
PAYROLL TAX TOTAL $28,734 $126,775 $155,509
EMPLOYEE BENEFITS:
0040 Retirement $11,141 $49,156 $60,297
0041 Workers Compensation $15,610 $68,873 $84,483
0042 $36,036 $158,989 $195,025
EMPLOYEE BENEFITS TOTAL $62,787 $277,018 $339,805
SALARY & BENEFITS GRAND TOTAL $2,198,589
FACILITIES/EQUIPMENT EXPENSES:
1010 Offsite Lease - Admin/Business Office $6,000
1011 Leased Equipment $14,443
1012 Telecommunications $39,229
1013 Utilities $84,383
1014 Maintenance $23,782
FACILITY/EQUIPMENT TOTAL $167,837
OPERATING EXPENSES:
1060 $38,878
1061 $18,729
1062 $6,365
1063 $3,180
1064 $2,808
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Housekeeping Supplies
Education & Training
Licenses
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (12 Bed)
Central Star Behavioral Health, Inc.
July 1, 2015 through June 30, 2016
Budget Categories - Total Proposed Budget
Revised Exhibit B-1
Page:8 of 21
Child-Adolescent Psychiatric Health Facility (12 Bed)
Central Star Behavioral Health, Inc.
July 1, 2015 through June 30, 2016
1065 $510
1066 $2,497
OPERATING EXPENSES TOTAL $72,967
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $304,595
1081 General Insurance $13,488
1082 Centralized fiscal service .05 $152,297
FINANCIAL SERVICES TOTAL $470,380
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $439,788
1088 Contract Therapist $25,355
1089 Supplies - House Meds $8,363
1090 Supplies - Medical $5,168
1091 Supplies Non-Medical $30,159
1092 Medical Records Supplies $673
1093 Food $38,005
1094 Supplies Non-Perishables $1,340
1096 Laundry & Linen $10,924
1097 Allowance $5,728
1098 Clothing $15,349
1099 Legal Fees $5,092
2000 Employee Benefits Other $3,121
SPECIAL EXPENSES TOTAL $589,065
FIXED ASSETS:
2000 Furniture & Fixture $2,500
2002 IT Minor Equipment $1,500
Assets (useful life more than 1 year and valued at more than $5,000)
2003 Intangible software/License Assets (useful life more than 1 year and valued at more than $100,000)$0
FIXED ASSETS TOTAL $4,000
TOTAL PROGRAM EXPENSES $3,502,838
Recruiting
Travel
Revised Exhibit B-1
Page:9 of 21
Child-Adolescent Psychiatric Health Facility (12 Bed)
Central Star Behavioral Health, Inc.
July 1, 2015 through June 30, 2016
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility 12 beds 4,392 $797.55 $3,502,840
DIRECT SERVICE REVENUE TOTAL 4,392 $3,502,840
$3,152,556
Cost Per Unit $797.55
FUNDING STREAMS REIMBURSEMENT Population Served Percentage
4000 Private Insurance 8%$280,227
4100 Uninsured 2%$70,057
4200 Medi-Cal FFP 90%$1,576,278
4300 2011 Realignment 90.0%$1,576,278
REVENUE TOTAL $3,502,840
Medi-cal Revenue
Revised Exhibit B-1
Page:10 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $0 $106,053 $106,053
0002 RN 3.20 $0 $272,202 $272,202
0003 LVN 2.80 $0 $129,915 $129,915
0004 Rehab Therapist 1.40 $0 $64,957 $64,957
0005 Rehab Aide 3.00 $0 $89,217 $89,217
0006 Youth Counselor 16.80 $0 $534,134 $534,134
0007 Admissions Coordinator 1.00 $0 $61,864 $61,864
0008 Family Advocate 1.00 $0 $35,682 $35,682
0009 Social Workers 2.80 $0 $182,499 $182,499
0010 Program Director 1.00 $0 $66,283 $66,283
0011 Cook 2.10 $0 $62,498 $62,498
0012 Administrator 1.00 $156,012 $0 $156,012
0013 UR/QA/Medical Records 1.00 $60,835 $0 $60,835
0014 HR/Training/Admin Asst 1.00 $69,476 $0 $69,476
0015 Billing Clerk 1.00 $24,304 $0 $24,304
0016 Maintenance Tech 0.50 $16,991 $0 $16,991
0017 Housekeeper 1.50 $31,849 $0 $31,849
SALARY TOTAL 42.10 $359,466 $1,605,304 $1,964,769
PAYROLL TAXES:
0030 FICA/MEDICARE $27,499 $122,806 $150,305
0031 SUI $1,941 $8,667 $10,608
0032 FUTA $3,379 $15,090 $18,469
PAYROLL TAX TOTAL $32,819 $146,563 $179,381
EMPLOYEE BENEFITS:
0040 Retirement $12,725 $56,828 $69,553
0041 Workers Compensation $17,830 $79,623 $97,453
0042 $41,159 $183,807 $224,966
EMPLOYEE BENEFITS TOTAL $71,713 $320,258 $391,972
SALARY & BENEFITS GRAND TOTAL $2,536,122
FACILITIES/EQUIPMENT EXPENSES:
1010 Offsite Lease - Admin/Business Office $18,727
1011 Leased Equipment $14,737
1012 Telecommunications $40,013
1013 Utilities $86,072
1014 Maintenance $24,260
1015 Security-Access Control System & Cameras $0
FACILITY/EQUIPMENT TOTAL $183,808
OPERATING EXPENSES:
1060 $40,340
1061 $21,793
1062 $6,487
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Housekeeping Supplies
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2016 through June 30, 2017
Budget Categories - Total Proposed Budget
Revised Exhibit B-1
Page:11 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2016 through June 30, 2017
1063 $6,487
1064 $5,728
1065 $520
1066 $2,546
OPERATING EXPENSES TOTAL $83,902
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $351,192
1081 General Insurance $13,758
1082 Centralized fiscal service .05 $198,174
FINANCIAL SERVICES TOTAL $563,124
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $563,257
1088 Contract Therapist $34,480
1089 Supplies - House Meds $11,371
1090 Supplies - Medical $7,026
1091 Supplies Non-Medical $59,584
1092 Medical Records Supplies $685
1093 Food $51,690
1094 Supplies Non-Perishables $1,824
1095 Laundry & Linen $14,859
1096 Allowance $7,785
1097 Clothing $20,869
1098 Legal Fees $5,190
1099 Employee Benefits Other $3,182
SPECIAL EXPENSES TOTAL $781,802
FIXED ASSETS:
2000 Furniture Replacement $10,000
2002 IT Minor Equipment $3,060
Assets (useful life more than 1 year and valued at more than $5,000)
2003 Intangible software/License Assets (useful life more than 1 year and valued at more than $100,000)$0
FIXED ASSETS TOTAL $13,060
TOTAL PROGRAM EXPENSES $4,161,818
Recruiting
Travel
Education & Training
Licenses
Revised Exhibit B-1
Page:12 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2016 through June 30, 2017
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility 16 beds 4,931 $844.00 $4,161,818
DIRECT SERVICE REVENUE TOTAL 4,931 $4,161,818
$3,745,636
Cost Per Unit $844.00
FUNDING STREAMS REIMBURSEMENT Population Served Percentage
4000 Private Insurance 8%$332,945
4100 Uninsured 2%$83,237
4200 Medi-Cal FFP 90%$1,872,818
4300 2011 Realignment 90.0%$1,872,818
REVENUE TOTAL $4,161,818
Medi-cal Revenue
Revised Exhibit B-1
Page:13 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $49,920 $33,280 $83,200
0002 RN 2.50 $0 $165,867 $165,867
0003 LVN 6.80 $0 $322,065 $322,065
0004 Rehab Therapist 1.00 $0 $52,136 $52,136
0005 Recreation Therapist 0.50 $0 $26,895 $26,895
0006 Rehab Aide 1.60 $0 $54,559 $54,559
0007 Youth Counselor 13.80 $0 $411,963 $411,963
0008 Unit Clerk 1.00 $0 $29,238 $29,238
0009 Family Advocate 1.00 $0 $33,486 $33,486
0010 Social Workers 4.00 $0 $247,927 $247,927
0011 Program Director 1.00 $0 $94,378 $94,378
0012 Cook 2.00 $0 $55,096 $55,096
0013 Administrator 0.60 $74,346 $0 $74,346
0014 UR/QA/Medical Records 0.50 $31,360 $0 $31,360
0015 HR/Training/Admin Asst 0.50 $55,335 $0 $55,335
0017 Housekeeper 1.20 $23,707 $0 $23,707
SALARY TOTAL 39.00 $234,667 $1,526,889 $1,761,557
PAYROLL TAXES:
0030 FICA/MEDICARE $17,952 $116,807 $134,759
0031 SUI $1,078 $13,783 $14,861
0032 FUTA $1,568 $20,048 $21,616
PAYROLL TAX TOTAL $20,598 $150,638 $171,236
EMPLOYEE BENEFITS:
0040 Retirement $5,163 $33,592 $38,754
0041 Workers Compensation $7,040 $45,807 $52,847
0042 $31,680 $206,130 $237,810
EMPLOYEE BENEFITS TOTAL $43,883 $285,528 $329,411
SALARY & BENEFITS GRAND TOTAL $2,262,203
FACILITIES/EQUIPMENT EXPENSES:
1011 Leased Equipment $22,535
1012 Telecommunications $40,469
1013 Utilities $87,798
1014 Maintenance $24,260
1015 $0
FACILITY/EQUIPMENT TOTAL $175,061
OPERATING EXPENSES:
1060 $36,301
1061 $16,200
1062 $6,487
1063 $6,379
1064 $5,838
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2017 through June 30, 2018
Budget Categories - Total Proposed Budget
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Housekeeping Supplies
Education & Training
Licenses
Revised Exhibit B-1
Page:14 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2017 through June 30, 2018
1065 $8,291
1066 $16,185
1067 Personnel Allocation from Starlight $103,424
1068 Centralized Program Services $136,499
1069 General Insurance $19,547
1070
OPERATING EXPENSES TOTAL $355,151
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $259,004
1081 Centralized fiscal service .05 $134,835
1082 Private Insur./Other County - Centralized fiscal service .10 $158,378
FINANCIAL SERVICES TOTAL $552,217
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $795,400
1088 Supplies - House Meds $11,604
1089 Supplies - Medical $35,860
1090 Medical Records Supplies $21,816
1091 Food $26,280
1092 Supplies - non-perishables $7,349
1093 Laundry & Linen $10,607
1094 Allowance $600
1095 Clothing $1,500
1096 Legal Fees $2,000
1097 Employee Benefits - Other $3,717
SPECIAL EXPENSES TOTAL $916,733
FIXED ASSETS:
2000 Furniture & Fixtures $2,500
2002 IT Minor Equipment $1,181
2003 IT Software $10,640
2004 IT Expense/Service $4,800
FIXED ASSETS TOTAL $19,121
TOTAL PROGRAM EXPENSES $4,280,486
Recruiting
Travel
Revised Exhibit B-1
Page:15 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2017 through June 30, 2018
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility 16 beds 5,840 $732.96 $4,280,486
DIRECT SERVICE REVENUE TOTAL 5,840 $4,280,486
$1,306,735
Cost Per Unit $732.96
FUNDING STREAMS REIMBURSEMENT Population Served Percentage
4000 Out-of-County 22%$844.00 $941,707
4100 Private Insurance 15%$929.00 $642,073
4101 Uninsured 2%$83,237
4102 Medi-Cal FFP 30.5%$1,306,735
4103 Realignment 30.5%$1,306,735
REVENUE TOTAL $4,280,486
Medi-cal Revenue
Revised Exhibit B-1
Page:16 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $51,418 $34,278 $85,696
0002 RN 2.50 $0 $170,843 $170,843
0003 LVN 6.80 $0 $331,727 $331,727
0004 Rehab Therapist 1.00 $0 $53,700 $53,700
0005 Recreation Therapist 0.50 $0 $27,702 $27,702
0006 Rehab Aide 1.60 $0 $56,196 $56,196
0007 Youth Counselor 13.80 $0 $424,322 $424,322
0008 Unit Clerk 1.00 $0 $30,115 $30,115
0009 Family Advocate 1.00 $0 $34,491 $34,491
0010 Social Workers 4.00 $0 $255,365 $255,365
0011 Program Director 1.00 $0 $97,209 $97,209
0012 Cook 2.00 $0 $56,749 $56,749
0013 Administrator 0.60 $76,576 $0 $76,576
0014 UR/QA/Medical Records 0.50 $32,301 $0 $32,301
0015 HR/Training/Admin Asst 0.50 $56,995 $0 $56,995
0017 Housekeeper 1.20 $24,418 $0 $24,418
SALARY TOTAL 39.00 $241,709 $1,572,697 $1,814,406
PAYROLL TAXES:
0030 FICA/MEDICARE $18,491 $120,311 $138,802
0031 SUI $1,078 $13,783 $14,861
0032 FUTA $1,568 $20,048 $21,616
PAYROLL TAX TOTAL $21,138 $154,142 $175,280
EMPLOYEE BENEFITS:
0040 Retirement $5,318 $34,599 $39,917
0041 Workers Compensation $7,251 $47,181 $54,432
0042 $32,631 $212,314 $244,945
EMPLOYEE BENEFITS TOTAL $45,200 $294,094 $339,294
SALARY & BENEFITS GRAND TOTAL $2,328,979
FACILITIES/EQUIPMENT EXPENSES:
1011 Leased Equipment $22,986
1012 Telecommunications $41,683
1013 Utilities $90,432
1014 Maintenance $24,988
1015 $0
FACILITY/EQUIPMENT TOTAL $180,089
OPERATING EXPENSES:
1060 $37,027
1061 $16,524
1062 $6,617
1063 $6,507
1064 $5,955
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2018 through June 30, 2019
Budget Categories - Total Proposed Budget
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Housekeeping Supplies
Education & Training
Licenses
Revised Exhibit B-1
Page:17 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2018 through June 30, 2019
1065 $8,457
1066 $16,509
1067 Personnel Allocation from Starlight $108,050
1068 Centralized Program Services $139,229
1069 General Insurance $19,938
1070 Private Insur./Other County - Centralized fiscal service .10
OPERATING EXPENSES TOTAL $364,811
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $264,184
1081 Centralized fiscal service .05 $138,667
1082 Private Insur./Other County - Centralized fiscal service .10 $162,879
FINANCIAL SERVICES TOTAL $565,730
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $819,262
1088 Supplies - House Meds $11,836
1089 Supplies - Medical $36,577
1090 Medical Records Supplies $22,252
1091 Food $26,806
1092 Supplies - non-perishables $7,496
1093 Laundry & Linen $10,819
1094 Allowance $612
1095 Clothing $1,530
1096 Legal Fees $2,040
1097 Employee Benefits - Other $3,791
SPECIAL EXPENSES TOTAL $943,023
FIXED ASSETS:
2000 Furniture & Fixtures $2,550
2002 IT Minor Equipment $1,205
2003 IT Software $10,853
2004 IT Expense/Service $4,896
FIXED ASSETS TOTAL $19,503
TOTAL PROGRAM EXPENSES $4,402,134
Recruiting
Travel
Revised Exhibit B-1
Page:18 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2018 through June 30, 2019
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility 16 beds 5,840 $753.79 $4,402,134
DIRECT SERVICE REVENUE TOTAL 5,840 $4,402,134
$1,342,650
Cost Per Unit $753.79
FUNDING STREAMS REIMBURSEMENT Population Served Percentage
4000 Out-of-County 22%$869.32 $968,469
4100 Private Insurance 15%$956.87 $660,321
4101 Uninsured 2%$88,043
4102 Medi-Cal FFP 30.5%$1,342,650
4103 Realignment 30.5%$1,342,650
REVENUE TOTAL $4,402,134
Medi-cal Revenue
Revised Exhibit B-1
Page:19 of 21
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 RN-DON 1.00 $52,960 $35,307 $88,267
0002 RN 2.50 $0 $175,968 $175,968
0003 LVN 6.80 $0 $341,679 $341,679
0004 Rehab Therapist 1.00 $0 $55,311 $55,311
0005 Recreation Therapist 0.50 $0 $28,533 $28,533
0006 Rehab Aide 1.60 $0 $57,882 $57,882
0007 Youth Counselor 13.80 $0 $437,052 $437,052
0008 Unit Clerk 1.00 $0 $31,019 $31,019
0009 Family Advocate 1.00 $0 $35,525 $35,525
0010 Social Workers 4.00 $0 $263,026 $263,026
0011 Program Director 1.00 $0 $100,126 $100,126
0012 Cook 2.00 $0 $58,451 $58,451
0013 Administrator 0.60 $78,874 $0 $78,874
0014 UR/QA/Medical Records 0.50 $33,270 $0 $33,270
0015 HR/Training/Admin Asst 0.50 $58,705 $0 $58,705
0017 Housekeeper 1.20 $25,151 $0 $25,151
SALARY TOTAL 39.00 $248,960 $1,619,878 $1,868,838
PAYROLL TAXES:
0030 FICA/MEDICARE $19,045 $123,921 $142,966
0031 SUI $1,078 $13,783 $14,861
0032 FUTA $1,568 $20,048 $21,616
PAYROLL TAX TOTAL $21,692 $157,752 $179,444
EMPLOYEE BENEFITS:
0040 Retirement $5,477 $35,637 $41,114
0041 Workers Compensation $7,469 $48,596 $56,065
0042 $33,610 $218,683 $252,293
EMPLOYEE BENEFITS TOTAL $46,556 $302,917 $349,473
SALARY & BENEFITS GRAND TOTAL $2,397,754
FACILITIES/EQUIPMENT EXPENSES:
1011 Leased Equipment $23,445
1012 Telecommunications $42,934
1013 Utilities $93,145
1014 Maintenance $25,737
1015 $0
FACILITY/EQUIPMENT TOTAL $185,261
OPERATING EXPENSES:
1060 $37,768
1061 $16,854
1062 $6,749
1063 $6,637
1064 $6,074
Line Item Description (Must be itemized)
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2019 through June 30, 2020
Budget Categories - Total Proposed Budget
Health Insurance (medical, vision, life, dental, 401k)
Purchased Services
Office Supplies
Housekeeping Supplies
Education & Training
Licenses
Revised Exhibit B-1
Page:20 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2019 through June 30, 2020
1065 $8,626
1066 $16,839
1067 Personnel Allocation from Starlight $113,353
1068 Centralized Program Services $142,014
1069 General Insurance $20,337
1070
OPERATING EXPENSES TOTAL $375,250
FINANCIAL SERVICES EXPENSES:
1080 Centralized Services $280,759
1081 Centralized fiscal service .05 $143,009
1082 Private Insur./Other County - Centralized fiscal service .10 $167,979
FINANCIAL SERVICES TOTAL $591,747
SPECIAL EXPENSES (Consultant/Etc.):
1087 Professional Fees & Consultation $843,840
1088 Supplies - House Meds $12,073
1089 Supplies - Medical $37,309
1090 Medical Records Supplies $22,697
1091 Food $27,342
1092 Supplies - non-perishables $7,646
1093 Laundry & Linen $11,036
1094 Allowance $624
1095 Clothing $1,561
1096 Legal Fees $2,081
1097 Employee Benefits - Other $3,867
SPECIAL EXPENSES TOTAL $970,076
FIXED ASSETS:
2000 Furniture & Fixtures $2,601
2002 IT Minor Equipment $1,229
2003 IT Software $11,070
2004 IT Expense/Service $4,994
FIXED ASSETS TOTAL $19,893
TOTAL PROGRAM EXPENSES $4,539,981
Recruiting
Travel
Revised Exhibit B-1
Page:21 of 21
Child-Adolescent Psychiatric Health Facility (16 Bed)
Central Star Behavioral Health, Inc.
July 1, 2019 through June 30, 2020
DIRECT SERVICE REVENUE:
Vol/Units of
Svc Rate $ Amt.
3000 Mental Health Services $0.00
(Assessment, Plan of Care, Individual/Family/Group Therapy, Rehab)
3100 Case Management, Linkage/Brokerage $0
3200 Crisis Intervention $0
3300 Medication Support $0
3301 Crisis Stabilization - Urgent Care $0
3302 Psychiatric Health Facility 16 beds 5,856 $775.27 $4,539,981
DIRECT SERVICE REVENUE TOTAL 5,856 $4,539,981
$1,384,694
Cost Per Unit $775.27
FUNDING STREAMS REIMBURSEMENT Population Served Percentage
4000 Out-of-County 22%$895.40 $998,796
4100 Private Insurance 15%$985.58 $680,997
4101 Uninsured 2%$90,800
4102 Medi-Cal FFP 30.5%$1,384,694
4103 Realignment 30.5%$1,384,694
REVENUE TOTAL $4,539,981
Medi-cal Revenue