HomeMy WebLinkAboutP-20-382 Master Agreement Psychological Evaluation Services.pdf
COUNTY OF FRESNO
Fresno, CA
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MASTER AGREEMENT
THIS AGREEMENT is made and entered into this ___________day of _____________, 2020,
by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
hereinafter referred to as “COUNTY”, and each CONTRACTOR, listed in Exhibit A “List of Contractors”,
attached hereto and by this reference incorporated herein, and collectively hereinafter referred to as
“CONTRACTOR(S)”, and such additional CONTRACTOR(S) as may, from time to time during the term of
this Agreement, be added by COUNTY. Reference in this Agreement to “parties” shall be understood to
refer to COUNTY and each individual CONTRACTOR, unless otherwise specified.
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), has a need for
licensed staff in order to provide psychiatric evaluation and court testimony services for Lanterman-
Petris-Short (LPS) Act Conservatees as defined by the Welfare and Insititutions Code Section 5350,
and reports for individuals deemed to be mentally incompetent to stand trial (IST) as defined by Penal
Code Section 1368, as well as additional services required by COUNTY as stated herein; and
WHEREAS, CONTRACTOR(S) is qualified and willing to provide licensed staff needed by the
COUNTY according to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1. SERVICES
CONTRACTOR(S) will provide the services as identified in Exhibit A and further detailed
in the descriptions below.
A. LPS Conservatorship Evaluation - CONTRACTOR(S) shall have licensed staff
provide psychiatric (M.D.) and psychological (Ph.D. and Psy.D.) evaluation and court testimony
services for LPS Act Conservatees as defined by the Welfare and Instittuions Code section 5350.
CONTRACTOR(S)’s licensed staff providing these services shall be licensed psychiatrists or
psychologists with at least five (5) years post-doctoral experience. CONTRACTOR(S) shall perform
evaluations for grave disability, including review of patient records, and provide declarations to the
probate court. Such evaluations shall be performed in an outpatient office-based setting, jail setting, or
1st October
P-20-382
COUNTY OF FRESNO
Fresno, CA
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treatment facility as needed, i.e., Adult Psychiatric Health Facility. CONTRACTOR shall testify in court
about patient’s diagnosis, grave disability, and placement of LPS conservatees. CONTRACTOR shall
work with the COUNTY’s Conservatorship Team and treatment facilities in obtaining information for
testifying, writing reports and treating the patient.
B. Adult IST Placement Evaluation - CONTRACTOR(S) shall have clinical staff that
are licensed and/or license-waivered mental health professionals, or a licensed psychiatrist (M.D.) or
psychologist (Ph.D. and Psy.D.) provide evaluation, report writing, and court testimony services for
adults deemed to be mentally IST as defined by Penal Code Section 1368. CONTRACTOR(S) must
have qualified staff to conduct court evaluations, with expertise in adult development and forensic
evaluation of adults for the purposes of competency program placement. Staff must be familiar with
competency standards and criteria used in evaluating competency and have received training in
conducting competency evaluations. Staff must be familiar with competency remediation for the
condition or conditions affecting competency in the adult’s case. CONTRACTOR(S) shall conduct
interviews within the COUNTY’s jail facilities, outpatient office-based setting, or treatment facility as
needed, i.e., Adult Psychiatric Health Facility; and complete reports to the criminal court on placement
of individuals for restoration to competency, and competency restoration. Additionally,
CONTRACTOR(S) may also be required to prepare reports for LPS conservatorships related to
individuals deemed to be IST and, in such case if CONTRACTOR(S) has a psychologist perform such
services they must have at least five (5) years post-doctoral experience.
C. Youth IST Placement Evaluation - CONTRACTOR(S) shall have clinical staff that
are licensed and/or license-waivered mental health professionals, or a licensed psychiatrist (M.D.) or
psychologist (Ph.D and Psy.D) provide evaluation, report writing, and court testimony services for
juvenile’s deemed to be mentally IST as defined by Penal Code Section 1368. Pursuant to WIC 709(b),
CONTRACTOR(S) must have qualified staff to conduct court evaluations, with expertise in child and
adolescent development and forensic evaluation of juveniles for the purposes of competency program
placement. Staff must be familiar with competency standards and criteria used in evaluation
competency and have received training in conducting juvenile competency evaluations. Staff must be
familiar with competency remdiation for the condition or conditions affecting competence in the
COUNTY OF FRESNO
Fresno, CA
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juvenile’s case. CONTRACTOR(S) shall conduct interviews within the Juvenile Justice Campus
facilities, outpatient office-based setting, or treatment facility as needed; and complete reports to the
criminal court on placement of indivuals for restoration to competency, and competency restoration.
D. CONTRACTOR(S) shall provide COUNTY verification of their staff licensure and
credentialing, as necessary.
E. CONTRACTOR(S) shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Statement of Qualifications (RFSQ) No. 20-052 dated March 12,
2020 and Addendum No. One (1) to COUNTY’s RFSQ dated March 19, 2020, collectively referred to
herein as COUNTY’s Revised RFSQ, and CONTRACTOR(S)’ response to said Revised RFSQ dated
June 8, 2020; all incorporated herein by reference and made part of this Agreement.
F. CONTRACTOR(S) shall compensate their licensed staff directly, including travel
costs. CONTRACTOR(S) approves COUNTY to retain income generated by services provided by
CONTRACTOR(S)’s licensed staff pursuant to this Agreement. COUNTY may bill Medi-Cal, and other
third-party sources, for services provided by CONTRACTOR(S)’s licensed staff to DBH clients. Such
revenues through patient services billing shall be retained by the COUNTY.
G. CONTRACTOR(S) shall align programs, services, and practices with the vision,
missing, and guiding principles of the DBH, as further described in Exhibit B, “Fresno County
Department of Behavioral Health Guiding Principles of Care Delivery”, attached hereto and by this
reference incorporated herein and made part of this Agreement.
H. Date and times of services provided by CONTRACTOR(S)‘s licensed staff shall
be mutually agreed upon by both COUNTY’s DBH Director, or designee, and CONTRACTOR(S).
2. TERM
The term of this Agreement shall be for a period of three (3) years, commencing on
October 1, 2020 through and including June 30, 2023. This Agreement may be extended for two (2)
additional consecutive twelve (12) month periods upon written approval of both parties no later than
thirty (30) days prior to the first day of the next twelve (12) month extension period. The DBH Director ,
or designee, is authorized to execute such written approval on behalf or COUNTY based on
CONTRACTOR(S)’s satisfactory performance.
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CONTRACTOR(S) added to this Agreement after the execution date shall become part
of the Agreement effective upon the date the executed signature page is received and approved by the
COUNTY’s DBH Director, or designee, as set forth in Section Eleven (11) of this Agreement. The June
30th termination date specified herein shall be the termination date for all CONTRACTOR(S),
regardless of when CONTRACTOR is added to this Agreement. Any twelve (12) month renewal period
of this Agreement for any CONTRACTOR already providing services under this Agreement shall
commence on July 1st of the then current fiscal year.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, is contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving CONTRACTOR(S) thirty (30) days advance written notice.
B. Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4) Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any
breach of this Agreement or any default which may then ex ist on the part of CONTRACTOR(S).
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. The COUNTY shall have the right to demand of the CONTRACTOR(S) the
repayment to the COUNTY of any funds disbursed to CONTRACTOR(S) under this Agreement, which
in the judgment of COUNTY were not expended in accordance with the terms of this Agreement. The
CONTRACTOR(S) shall promptly refund any such funds upon demand.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY or CONTRACTOR(S) upon the giving of thirty (30) days
advance written notice of an intention to terminate.
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Fresno, CA
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4. COMPENSATION
COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S) agrees to receive
compensation for actual expenditures incurred in accordance with the individual CONTRACTOR’s
service rates approved by the COUNTY’s DBH Director, or designee attached hereto as Exhibit C-1 et.
seq. and incorporated herein by this reference.
In no event shall services performed under this Agreement be in excess of Two Hundred
Thousand and No/100 Dollars ($200,000.00) for all CONTRACTOR(S) combined. In the event the
maximum compensation amount in any individual fiscal year of Forty Thousand and No/100 Dollars
($40,000.00) is not fully expended, said remaining unspent funding amounts shall rollover to each
subsequent fiscal year’s established maximum compensation.
A. The hourly rate shall be prorated on a fifteen (15) minute basis. COUNTY shall
pay for actual hours worked by the CONTRACTOR(S)’s licensed staff.
B. It is understood that all expenses incidental to CONTRACTOR(S)’s performance
of services under this Agreement shall be borne by CONTRACTOR(S). If CONTRACTOR(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 CONTRACTOR(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 Five (5) herein. Payments shall
be made after receipt and verification of actual expenditures incurred by CONTRACTOR(S) in the
performance of this Agreement and shall be documented to COUNTY on a monthly basis by the tenth
(10th) of the month following the month of said expenditures.
D. 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 Director,
or designee. If CONTRACTOR(S) should fail to comply with any provision of this Agreement, COUNTY
shall be relieved of its obligation for further compensation. All final claims and/or any final budget
modification requests shall be submitted by CONTRACTOR(S) to COUNTY within sixty (60) days
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Fresno, CA
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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(S) pursuant to the terms and conditions of this Agreement shall
automatically revert to COUNTY.
E. The services provided by CONTRACTOR(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 payment to CONTRACTOR(S). 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.
F. CONTRACTOR(S) 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(S). CONTRACTOR(S) shall not receive
reimbursement for any units of services rendered that are disallowed or denied by the COUNTY’s
utilization review process.
G. It is understood by CONTRACTOR(S) and COUNTY that this Agreement is
funded with mental health funds to serve individuals who have serious mentally illness (SMI) or have
serious emotional disturbances (SED), often with co-occurring substance use disorders. It is further
understood by CONTRACTOR(S) and COUNTY that funds shall be used to support appropriately
integrated and documented treatment services for co-occurring mental health and substance use
disorders and that integrated services can be documented in assessments, interventions, and program
notes documenting linkages and services.
5. INVOICING
A. CONTRACTOR(S) shall invoice COUNTY in arrears by the tenth (10th) day of
each month for actual expenses incurred during the prior month electronically to: 1)
dbhinvoices@fresnocountyca.gov, 2) dbhinvoicereview@fresnocountyca.gov, and 3)
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Fresno, CA
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dbhcontractedservicesdivision@fresnocountyca.gov and a carbon copy email to the assigned
COUNTY’s DBH Staff Analyst. Invoices shall reflect services provided at the DBH facilities and program
sites requested by DBH and shall include dates and hours services were provided as requested by the
COUNTY. Invoices shall be accompanied by a signed timecard from the CONTRACTOR’s licensed
staff showing dates and hours worked and is verified and approved by the Department of Behavioral
Health.
After CONTRACTOR(S) renders service to DBH clients, CONTRACTOR(S) will
invoice COUNTY for actual services delivered and 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 Four (4) 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 shall
have the right to deny payment of any additional invoices received.
B. CONTRACTOR(S) 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(S) will be
responsible for any disallowances related to inadequate documentation.
C. CONTRACTOR(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. The necessary data can be provided by a variety of means, including but not limited to:
1) direct data entry into COUNTY’s information system, 2) providing an electronic file compatible with
COUNTY’s information system, or 3) integration between COUNTY’s information system and
CONTRACTOR’s information system(s). At a mutually agreeable time, CONTRACTOR and COUNTY’s
DBH shall discuss and agree as to the most efficient data collection method to collect Medi-Cal and any
other third party revenue as indicated above.
D. Medi-Cal billing shall be in accordance with the COUNTY’s Mental Health Plan.
CONTRACTOR(S) must comply with the “Fresno County Mental Health Plan Compliance Plan and
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Code of Conduct” set forth in Exhibit D, attached hereto and by this reference incorporated herein and
made part of this Agreement.
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 ev ent that a
Medi-Cal billable service is disapproved, COUNTY may, at its sole discretion, withhold compensation or
set off from other payments due the amount of said disapproved services. CONTRACTOR shall be
responsible for audit exceptions to ineligible dates of services or incorrect application of utilization
review requirements.
7. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR(S)
under this Agreement, it is mutually understood and agreed that CONTRACTOR(S), including any and
all of CONTRACTOR(S)’s officers, agents, and employees will at all times be acting and performing as
independent contractors, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venture, partner, or associate of COUNTY. Furthermore, COUNTY shall have no right
to control or supervise or direct the manner or method by which each CONTRACTOR shall perform its
work and function. However, COUNTY shall retain the right to administer this Agreement so as to
verify that each CONTRACTOR is performing their obligations in accordance with the terms and
conditions thereof. CONTRACTOR(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, each CONTRACTOR shall have
absolutely no right to employment rights and benefits available to COUNTY employees. Each
CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees all
legally-required employee benefits. In addition, CONTRACTOR(S) shall be solely responsible and
save COUNTY harmless from all matters relating to payment of CONTRACTOR(S)’s employees,
including compliance with Social Security, withholding, and all other regulations governing such
matters. It is acknowledged that during the term of this Agreement, CONTRACTOR(S) may be
providing services to others unrelated to COUNTY or to this Agreement.
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8. 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. Changes to the rates of compensation for
services provided by each CONTRACTOR can be made once annually and shall be made upon the
written approval of the individual CONTRACTOR seeking the change and COUNTY’s DBH Director or
designee, without exceeding the contract maximum of this Agreement.
9. 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 the individual CONTRACTOR
seeking to make such assignment.
10. HOLD-HARMLESS
Each CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's
request, defend COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by each CONTRACTOR, its
officers, agents or employees under this Agreement, and from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
any person, firm or corporation who may be injured or damaged by the performance, or failure to
perform, of each CONTRACTOR, their officers, agents or employees under this Agreement.
Each CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of
California audit exceptions resulting from noncompliance herein on the part of each CONTRACTOR.
11. INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR(S) or any
third parties, each CONTRACTOR, at its sole expense, shall maintain in full force and 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 Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Four Million
Dollars ($4,000,000). This policy shall be issued on a per occurrence basis.
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COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire
legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits no less than One
Million Dollars ($1,000,000) per accident for bodily injury and property damage.
Coverage should include any automobile used in connection with this
Agreement. If CONTRACTOR(S) employees are not covered by
CONTRACTOR(S)’ automobile liability insurance policy, CONTRACTOR(S) shall
ensure that each employee as part of this Agreement procures and maintains
their own private automobile coverage in force during the term of this Agreement,
at the employee’s sole cost and expense.
C. Real And Personal Property
As applicable, CONTRACTOR(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 purchase and owned property,
at a minimum.
All Risk Property Insurance
As applicable, CONTRACTOR(S) will provide property coverage for the full
replacement value of the COUNTY’s personal property in the possession of
CONTRACTOR(S) and/or used in the execution of this Agreement. COUNTY
will be identified on an appropriate certificate of insurance as the certificate
holder and will be named as an Additional Loss Payee on the Property Insurance
Policy.
D. Professional Liability
If CONTRACTOR(S) employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., L.M.F.T.) in providing services, Professional Liability Insurance with
limits of not less than One Million Dollars ($1,000,000) per occurrence, Three
Million Dollars ($3,000,000) annual aggregate. CONTRACTOR(S) agrees that it
shall maintain, at its sole expense, in full force and effect for a period of five (5)
years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein. The
retroactive date must be shown and must be before the effective date of the
Agreement or the beginning of services performed under the Agreement. The
policy must be maintained, and evidence of insurance must be provided for at
least five (5) years after completion of Agreement services. If coverage is
canceled or non-renewed, and not replaced with another claims-made policy
form with a retroactive date prior to the Agreement effective date, the
CONTRACTOR(S) must purchase “extended reporting” coverage for a minimum
of five (5) years after completion.
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E. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
F. Child Abuse/Molestation and Social Services Coverage
CONTRACTOR(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 One Million Dollars ($1,000,000) per occurrence
with Two Million Dollars ($2,000,000) annual aggregate. The policies are to be
on a per occurrence basis.
H. Cyber Liability
Cyber Liability Insurance, with limits not less than Two Million Dollars
($2,000,000) per occurrence or claim, Two Million Dollars ($2,000,000)
aggregate. Coverage shall be sufficiently broad to respond to duties and
obligations undertaken by CONTRACTOR(S) in this agreement and shall
include, but not be limited to, claims involving infringement of intellectual
property, including but not limited to infringement of copyright, trademark, trade
dress, invasion of privacy violations, information theft, damage to or destruction
of electronic information, release of private information, alteration of electronic
information, extortion and network security. The policy shall provide coverage for
breach response costs as well as regulatory fines and penalties as well as credit
monitoring expenses with limits sufficient to respond to these obligations.
Additional Requirements Relating to Insurance
CONTRACTOR(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 contributing with insurance provided under CONTRACTOR(S)’s policies herein.
This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance written
notice given to COUNTY.
CONTRACTOR(S) hereby waives its rights to recover from COUNTY, its officers,
agents, and employees any amounts paid by the policy of worker’s compensation insurance required
by this Agreement. CONTRACTOR(S) is solely responsible to obtain any endorsement to such policy
that may be necessary to accomplish such waiver of subrogation, but CONTRACTOR(S)’ waiver of
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subrogation under this paragraph is effective whether or not CONTRACTOR obtains such an
endorsement.
Within thirty (30) days from the date CONTRACTOR(S) signs this Agreement,
CONTRACTOR(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, California, 93703, Attention: Adult Services Division, Forensic
Behavioral Health Services Unit or electronically to dhbcontractedservicesdivision@fresncountyca.gov
with a copy to the assigned COUNTY’s DBH Staff Analyst, stating that such insurance coverages have
been obtained and are in full force; that the County of Fresno, its officers, agents and employees will
not be responsible for any premiums on the policies; that such Commercial General Liability insurance
names the County of Fresno, its officers, agents and employees, individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned; that such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents and employees, shall be excess only and not
contributing with insurance provided under CONTRACTOR(S)’s policies herein; and that this insurance
shall not be cancelled or changed without a minimum of thirty (30) days advance, written notice given to
COUNTY.
In the event CONTRACTOR(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.
12. LICENSES/CERTIFICATES
Throughout the term of this Agreement, CONTRACTOR(S) and CONTRACTOR(S)’s
staff shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions
necessary for the provision of the services hereunder and required by the laws and regulations of the
United States of America, State of California, the County of Fresno, and any other applicable
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governmental agencies. CONTRACTOR(S) shall notify COUNTY immediately in writing of its inability
to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions
irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR(S) and
CONTRACTOR(S)’s staff shall comply with all applicable laws, rules or regulations, as may now exist
or be hereafter changed.
13. ADDITIONS/DELETIONS OF CONTRACTOR(S)
COUNTY’s DBH Director or designee reserves the right at any time during the term of
this Agreement to add new CONTRACTOR(S) to those listed in Exhibit A with oversight and approval
by Internal Services Department – Purchasing Division. It is understood that any such additions will not
affect compensation paid to any other CONTRACTOR, and therefore such additions may be made by
COUNTY without notice to or approval of the other CONTRACTOR(S) under this Agreement. These
same provisions shall apply to the deletion of any CONTRACTOR(S) contained in Exhibit A, except that
deletions shall be by written mutual agreement between the COUNTY and the particular
CONTRACTOR to be deleted, or shall be in accordance with the provisions of Section Three (3) of this
Agreement.
14. RECORDS
During site visits, COUNTY shall be allowed to review records of services provided,
including the goals and objectives of the treatment plan, and how the therapy provided is achieving the
goals and objectives. All medical records shall be maintained for a minimum of ten (10) years from the
date of the end of the Agreement.
15. REPORTS
A. Outcome Reports
CONTRACTOR(S) shall submit to COUNTY’s DBH service outcome reports, as
requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to change at
the discretion of COUNTY’s DBH Director or designee.
B. Additional Reports
CONTRACTOR(S) shall also furnish to COUNTY such statements, records,
reports, data, and other information as COUNTY may request pertaining to matters covered by t his
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Agreement. In the event that CONTRACTOR(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, CONTRACTOR(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.
15. MONITORING
CONTRACTOR(S) agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
the State Department of Health Care Services, 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
CONTRACTOR(S)’s programs, in order to ensure compliance with the terms and conditions of this
Agreement.
16. 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.
17. COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR(S) recognizes that COUNTY operates its mental health programs under
an agreement with the State of California Department of Health Care Services, and that under said
agreement the State imposes certain requirements on COUNTY and its subcontractors.
CONTRACTOR(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.
18. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR(S) shall inform every client of their rights under the COUNTY’s Mental
Health Plan as described in “Fresno County Mental Health Plan Grievances and Appeals Process”
Exhibit F, attached hereto and by this reference incorporated herein and made part of this Agreement.
CONTRACTOR(S) shall also file an incident report for all incidents involving clients, following the
COUNTY’s DBH “Protocol for Completion of Incident Report” policy and procedure guide and using the
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“Incident Report” protocol and user guide identified in Exhibit G, attached hereto and by this reference
incorporated herein and made part of this Agreement.
19. CONFIDENTIALITY
All services performed by CONTRACTOR(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.
20. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR(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 CONTRACTOR(S) acknowledge that the exchange of PHI between them
is only for treatment, payment, and health care operations.COUNTY and CONTRACTOR(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 CONTRACTOR(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).
21. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter
into a contractual relationship with the COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR(S) by the COUNTY, including but not limited to the following:
A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
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CONTRACTOR(S) may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1) CONTRACTOR(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. CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR(S) may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief Information
Officer, and/or designee(s), including but not limited to mobile storage devices. If data is approved to
be transferred, data must be stored on a secure server approved by the COUNTY and transferred by
means of a Virtual Private Network (VPN) connection, or another type of secure connection. Said data
must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR(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. CONTRACTOR(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.
E. CONTRACTOR(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.
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G. CONTRACTOR(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 CONTRACTOR(S)’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information provided
to CONTRACTOR(S). CONTRACTOR(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.
CONTRACTOR(S) will be responsible for all costs incurred as a result of providing the required
notification.
22. NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR(S) and its subcontractors
shall not deny the agreement’s benefits to any person on the basis of race, religious creed, color,
national origin, ancestry, physical disability, mental disability, medical condition, genetic information,
marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and
veteran status, nor shall they discriminate unlawfully against any employee or applicant for employment
because of race, religious creed, color, national origin, ancestry, physical disability, mental disability,
medical condition, genetic information, marital status, sex, gender identity, gender expression, age,
sexual orientation, or military and veteran status.
CONTRACTOR(S) shall ensure that the evaluation and treatment of employees and
applicants for employment are free of such discrimination. CONTRACTOR(S) and subcontractors shall
comply with the provisions of the Fair Employment and Housing Act (Gov. Code §12800 et seq.), the
regulations promulgated thereunder (Cal. Code Regs., tit. 2, §11000 et seq.), the provisions of Article
9.5, Chapter 1, Part 1, Division 3, Title 2 of the Government Code (Gov. Code §11135-11139.5), and
the regulations or standards adopted by the awarding state agency to implement such article.
CONTRACTOR(S) shall permit access by representatives of the Department of Fair Employment and
Housing and the awarding state agency upon reasonable notice at any time during the normal business
hours, but in no case less than twenty-four (24) hours notice, to such of its books, records, accounts,
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and all other sources of information and its facilities as said department or agency shall require to
ascertain compliance with this clause. CONTRACTOR(S) and its subcontractors shall give written
notice of their obligations under this clause to labor organizations with which they have a collective
bargaining or other agreement. (See Cal. Code Regs., tit. 2, §11105.) CONTRACTOR(S) shall include
the non-discrimination and compliance provisions of this clause in all subcontracts to perform work
under this Agreement.
23. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v) (1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four
(4) years after the furnishing of services under this Agreement, CONTRACTOR(S) shall make
available, upon written request of the Secretary of the United States Department of Health and Human
Services, or upon request of the Comptroller General of the United States General Accounting Office,
or any of their duly authorized representatives, a copy of this Agreement and such books, documents,
and records as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR(S) under this Agreement. CONTRACTOR(S) further agrees that in the event
CONTRACTOR(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 Agreement shall contain a clause to the effect that until the
expiration of four (4) years after the furnishing of such services pursuant to such subcontract, the
related organizations shall make available, upon written request of the Secretary of the United States
Department of Health and Human Services, or upon request of the Comptroller General of the United
States General Accounting Office, or any of their duly authorized representatives, a copy of such
subcontract and such books, documents, and records of such organiza tion as are necessary to verify
the nature and extent of such costs.
24. SINGLE AUDIT CLAUSE
A. If CONTRACTOR(S) expends Seven Hundred Fifty Thousand and No/100
Dollars ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR(S) agrees
to conduct an annual audit in accordance with the requirements of the Single Audit Standards as set
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forth in Office of Management and Budget (OMB) 2 CFR 200. CONTRACTOR(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 were negative findings, CONTRACTOR(S) must include
a corrective action plan signed by an authorized individual. CONTRACTOR(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 Finance Division for review within nine (9) months of the end of any fiscal
year in which funds were expended and/or received for the program. Failure to perform the requisite
audit functions as required by this Agreement may result in COUNTY performing the necessary audit
tasks, or at COUNTY’s option, contracting with a public accountant to perform said audit, or may result
in the inability of COUNTY to enter into future agreements with CONTRACTOR(S). All audit costs
related to this Agreement are the sole responsibility of CONTRACTOR(S).
B. A single audit report is not applicable if CONTRACTOR’s Federal contracts do
not exceed the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or
CONTRACTOR(S)’s only funding is through Drug related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be
submitted by CONTRACTOR(S) to COUNTY as a minimum requirement to attest to CONTRACTOR’s
solvency. Said audit report shall be delivered to COUNTY’s DBH Business Office for review, no later
than nine (9) months after the close of the fiscal year in which the funds supplied through this
Agreement are expended. Failure to comply with this act may result in COUNTY performing the
necessary audit tasks or contracting with a qualified accountant to perform said audit. All audit costs
related to this Agreement are the sole responsibility of CONTRACTOR(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 CONTRACTOR(S) at
COUNTY’s cost, as determined by COUNTY’s Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR(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
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pending matters, whichever is later.
25. COMPLIANCE
CONTRACTOR(S) agrees to comply with the COUNTY’s Contractor Code of Conduct
and Ethics and the COUNTY’s Compliance Program in accordance with Exhibit D. Within thirty (30)
days of entering into this Agreement with the COUNTY, CONTRACTOR(S) shall have all of
CONTRACTOR(S)’s employees, agents and subcontractors providing services under this Agreement
certify in writing, that he or she has received, read, understood, and shall abide by the Contractor Code
of Conduct and Ethics. CONTRACTOR(S) shall ensure that within thirty (30) days of hire, all new
employees, agents and subcontractors providing services under this Agreement shall certify in writing
that he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and
Ethics. CONTRACTOR(S) understands that the promotion of and adherence to the Code of Conduct is
an element in evaluating the performance of CONTRACTOR(S) and its employees, agents and
subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training, and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement traini ng. All new employees, agents and
subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual who
is required to attend training shall certify in writing that he or she has received the required training.
The certification shall specify the type of training received and the date received. The certification shall
be provided to the COUNTY’s Compliance Officer at 1925 E. Dakota Ave, Fresno, CA 93726.
CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any penalty imposed upon
COUNTY by the Federal Government as a result of CONTRACTOR(S)’s violation of the terms of this
Agreement.
26. ASSURANCES
In entering into this Agreement, CONTRACTOR(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
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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 CONTRACTOR(S) is ineligible on these
grounds, COUNTY will remove CONTRACTOR(S) from responsibility for, or involvement with,
COUNTY’s business operations related to the Federal Health Care Programs and shall remove such
CONTRACTOR(S) from any position in which CONTRACTOR(S)’s compensation, or the items or
services rendered, ordered or prescribed by CONTRACTOR(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
CONTRACTOR(S) is reinstated into participation in the Federal Health Care Programs.
A. If COUNTY has notice that CONTRACTOR(S) or its officers has been charged
with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during
the term on any contract, CONTRACTOR(S) and COUNTY shall take all appropriate actions to ensure
the accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR(S) cease providing services until resolution
of the charges or the proposed exclusion.
B. CONTRACTOR(S) agrees that all potential new employees of
CONTRACTOR(S) or subcontractors of CONTRACTOR(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 ineligible to participate in the Federal Health Care
Programs; (2) they have been convicted of a criminal offense related to the provision of health care
items or services; and or (3) they have been reinstated to participation in the Federal Health Care
Programs after a period of exclusion, suspension, debarment, or ineligibility.
1) In the event the potential employee or subcontractor informs
CONTRACTOR(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 CONTRACTOR(S)
hires or engages such potential employee or subcontractor, CONTRACTOR(S) will ensure that said
employee or subcontractor does no work, either directly or indirectly relating to services provided to
COUNTY.
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2) Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Four (4) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR(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. CONTRACTOR(S) shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement (1) are not currently excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have not
been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
CONTRACTOR(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, CONTRACTOR(S) will ensure that said employee or
subcontractor does no work, either direct or indirect, relating to services provided to COUNTY.
1) CONTRACTOR(S) agrees to notify COUNTY immediately during the term
of this Agreement whenever CONTRACTOR(S) learns that an employee or 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 the Termination Section Four (4) of this Agreement, or require adequate
assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR(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.
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D. CONTRACTOR(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 CONTRACTOR’s compliance with the provisions of this Section.
E. CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any
penalty imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation
of CONTRACTOR’s obligations as described in this Section.
27. PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for CONTRACTOR(S)’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 One (1) of this Agreement
shall be allowed as necessary to raise public awareness about the availability of such specific services
when approved in advance by COUNTY’s DBH Director or designee and at a cost to be provided in
Section Five (5) 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).
28. COMPLAINTS
CONTRACTOR(S) shall log complaints and the disposition of all complaints from a client
or a client's family. CONTRACTOR(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. In addition, CONTRACTOR(S) shall provide
details and attach documentation of each complaint with the log. CONTRACTOR(S) shall post signs
informing clients of their right to file a complaint or grievance. CONTRACTOR(S) shall notify COUNTY
of all incidents reportable to state licensing bodies that affect COUNTY clients upon receipt of a
complaint.
Within ten (10) days after each incident or complaint affecting COUNTY clients,
CONTRACTOR(S) shall provide COUNTY with information relevant to the complaint, investigative details
of the complaint, the complaint and CONTRACTOR(S)’s disposition of, or corrective action taken to
resolve the complaint. In addition, CONTRACTOR(S) shall inform every client of their rights as set forth in
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Exhibit F. CONTRACTOR(S) shall file an incident report for all incidents involving clients, following the
protocol and user guide identified in Exhibit G.
29. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence:
A. CONTRACTOR(S) shall not discriminate against beneficiaries based on race,
color, national origin, sex, disability, or religion. CONTRACTOR(S) shall ensure that a limited and/or no
English proficient beneficiary is entitled to equal access and participation in federally funded programs
through the provision of comprehensive and quality bilingual services pursuant to 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.
B. CONTRACTOR(S) shall comply with requirements of policies and procedures for
ensuring access and appropriate use of trained interpreters and material translation services for all
limited and/or no English proficient beneficiaries, including, but not limited to, assessing the cultural and
linguistic needs of the beneficiaries, training of staff on the policies and procedures, and monitoring its
language assistance program. CONTRACTOR(S)’s policies and procedures shall ensure compliance of
any subcontracted providers with these requirements.
C. CONTRACTOR(S) shall notify its beneficiaries that oral interpretation is available
for any language and written translation is available in prevalent languages and that auxiliary aids and
services are available upon request, at no cost and in a timely manner for limited and/or no English
proficient beneficiaries and/or beneficiaries with disabilities. CONTRACTOR(S) shall avoid relying on an
adult or minor child accompanying the beneficiary to interpret or facilitate communication; however, if the
beneficiary refuses language assistance services, the CONTRACTOR(S) must document the offer, refusal
and justification in the beneficiary’s file.
D. CONTRACTOR(S) shall ensure that employees, agents, subcontractors, and/or
partners who interpret or translate for a beneficiary or who directly communicate with a beneficiary in a
language other than English (1) have completed annual training provided by COUNTY at no cost to
CONTRACTOR(S); (2) have demonstrated proficiency in the beneficiary’s language; (3) can effectively
communicate any specialized terms and concepts specific to CONTRACTOR(S)’s services; and (4)
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adheres to generally accepted interpreter ethic principles. As requested by COUNTY, CONTRACTOR(S)
shall identify all who interpret for or provide direct communication to any program beneficiary in a language
other than English, and identify when the CONTRACTOR(S) last monitored the interpreter for language
competence.
E. CONTRACTOR(S) shall submit to COUNTY for approval, within ninety (90) days
from date of contract execution, CONTRACTOR(S)’s plan to address all fifteen (15) National Standards for
Culturally and Linguistically Appropriate Service (CLAS), as published by the Office of Minority Health and
as set forth in Exhibit H “National Standards on Culturally and Linguistically Appropriate Services”,
attached hereto and incorporated herein by reference and made part of this Agreement. As the CLAS
standards are updated, CONTRACTOR(S)’s plan must be updated accordingly. As requested by
COUNTY, CONTRACTOR(S) shall be responsible for conducting an annual CLAS self-assessment and
providing the results of the self-assessment to the COUNTY. The annual CLAS self-assessment
instruments shall be reviewed by the COUNTY and revised as necessary to meet the approval of the
COUNTY.
F. Cultural competency training for CONTRACTOR(S) staff should be substantively
integrated into health professions education and training at all levels, both academically and functionally,
including core curriculum, professional licensure, and continuing professional development programs. As
requested by COUNTY, CONTRACTOR(S) shall report on the completion of cultural competency trainings
to ensure direct service providers are completing a minimum of one (1) cultural competency training
annually.
G. CONTRACTOR(S) shall create and sustain a forum that includes staff at all agency
levels to discuss cultural competence. COUNTY encourages a representative from CONTRACTOR(S)’s
forum to attend COUNTY’s Cultural Humility Committee.
30. AMERICANS WITH DISABILITIES ACT
CONTRACTOR(S) agrees to ensure that deliverables developed and produced,
pursuant to this Agreement, shall comply with the accessibility requirements of Section 508 of the
Rehabilitation Act and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. § 794 (d)),
and regulations implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal
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Regulations. In 1998, Congress amended the Rehabilitation Act of 1973 to require Federal agencies to
make their electronic and information technology (EIT) accessible to people with disabilities. California
Government Code section 11135 codifies section 508 of the Act requiring accessibility of electronic and
information technology.
31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR(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,
and 455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR(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. CONTRACTOR(S) shall submit this form to the COUNTY’s
DBH within thirty (30) days of the effective date of this Agreement. Additionally, CONTRACTOR (S)
shall report any changes to this information within thirty-five (35) days of occurrence by completing
Exhibit I, “Disclosure of Ownership and Control Interest Statement.” Submissions shall be scanned
portable document format (pdf) copies and are to be sent via email to COUNTY’s DBH assigned Staff
Analyst.
CONTRACTOR(S) is required to submit a set of fingerprints for any person with a five
(5) percent or greater direct or indirect ownership interest in CONTRACTOR(S). COUNTY may
terminate this Agreement where any person with a five (5) percent or greater direct or indirect
ownership interest in the CONTRACTOR(S) did not submit timely and accurate information and
cooperate with any screening method required in CFR, Title 42, Section 455.416. Submissions shall be
scanned pdf copies and are to be sent via email to
DBHContractedServicesDivision@fresnocountyca.gov. COUNTY may deny enrollment or terminate
this Agreement where any person with a five (5) percent or greater direct or indirect ownership interest
in CONTRACTOR(S) has been convicted of a criminal offense related to that person’s involvement with
the Medicare, Medicaid, or Title XXI program in the last ten (10) years.
32. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
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CONTRACTOR(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
“CONTRACTOR(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
transaction;
2) Violation of a federal or state antitrust statute;
3) Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4) False statements or receipt of stolen property.
B. Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR (S)
from further business consideration. The information will be considered as part of the det ermination
of whether to continue and/or renew the Contract and any additional information or explanation that a
CONTRACTOR(S) elects to submit with the disclosed information will be considered. If it is later
determined that the CONTRACTOR (S) failed to disclose required information, any contract awarded
to such CONTRACTOR(S) may be immediately voided and terminated for material failure to comply
with the terms and conditions of the award.
CONTRACTOR(S) must sign a “Certification Regarding Debarment, Suspe nsion, and
Other Responsibility Matters - Primary Covered Transactions” in the form set forth in Exhibit J,
attached hereto and by this reference incorporated herein and made part of this Agreement.
Additionally, CONTRACTOR (S) must immediately advise the C ounty in writing if, during the term of
this Agreement: (1) CONTRACTOR (S) becomes suspended, debarred, excluded or ineligible for
participation in federal or state funded programs or from receiving federal funds as listed in the
excluded parties’ list sys tem (http://www.epls.gov ); or (2) any of the above listed conditions become
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applicable to CONTRACTOR (S). CONTRACTOR(S) shall indemnify, defend and hold the COUNTY
harmless for any loss or damage resulting from a convict ion, debarment, exclusion, ineligibility or
other matter listed in the signed Certification Regarding Debarment, Suspension, and Other
Responsibility Matters.
32. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR(S) is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this agreement, the CONTRACTOR (S)
changes its status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR(S) is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the
CONTRACTOR(S) is a party and in which one or more of its directors has a material financial interest.
Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
by completing and signing a “Self-Dealing Transaction Disclosure Form”, attached hereto as Exhibit K
and by this reference incorporated herein and made part of this Agreement, and submitting it to the
COUNTY’s DBH prior to commencing with the self-dealing transaction or immediately thereafter.
33. AUDITS AND INSPECTIONS
After reasonable notice to CONTRACTOR(S) shall, at any time during business hours,
and as often as the COUNTY may deem necessary, make available to the COUNTY for examination all
of its records and data with respect to the matters covered by this Agreement. The CONTRACTOR(S)
shall, upon request by the COUNTY, permit the COUNTY to audit and inspect all such records and
data necessary to ensure CONTRACTOR(S)’s compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR(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. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
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COUNTY CONTRACTOR
Director, Fresno County SEE EXHIBIT A
Department of
Behavioral Health
1925 E. Dakota Ave
Fresno, CA 93726
All notices between COUNTY and CONTRACTOR(S) provided for or permitted under
this Agreement must be in writing and delivered either by personal service, by first -class United States
mail, by an overnight commercial courier service, or by telephonic facsimile transmission. A notice
delivered by personal service is effective upon service to the recipient. A notice delivered by first-class
United States mail is effective three (3) COUNTY business days after deposit in the United States mail,
postage prepaid, addressed to the recipient. A notice delivered by an overnight commercial courier
service is effective one (1) COUNTY business day after deposit with the overnight commercial courier
service, delivery fees prepaid, with delivery instructions given for next day delivery, addressed to the
recipient. A notice delivered by telephonic facsimile is effective when transmission to the recipient is
completed (but, if such transmission is completed outside of COUNTY business hours, then such
delivery shall be deemed to be effective at the next beginning of a COUNTY business day), provided
that the sender maintains a machine record of the completed transmission. For all claims arising out of
or related to this Agreement, nothing in this section establishes, waives, or modifies any cla ims
presentation requirements or procedures provided by law, including but not limited to the Government
Claims Act (Division 3.6 of Title 1 of the Government Code, beginning with section 810).
35. SEVERABILITY
If any non-material term, provision, covenant, or condition of this Agreement is held by a
court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions shall
remain in full force and effect, and shall in no way be affected, impaired or invalidated.
36. SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create
a joint venture among the individual CONTRACTOR(S). By execution of this Agreement,
CONTRACTOR(S) understand that a separate Agreement is formed between each individual
CONTRACTOR and COUNTY.
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37. GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
38. ENTIRE AGREEMENT
This Agreement, including all Exhibits, Revised RFSQ No. 20-052 and CONTRACTOR(S)’ Response
thereto, constitutes the entire agreement between CONTRACTOR(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. In the event of any inconsistency among these documents, the
inconsistency shall be resolved by giving precedence in the following order of priority: (1) to this
Agreement, including all Exhibits; (2) to the Revised RFSQ; and (3) to the CONTRACTOR(S)’
Response to the Revised RFSQ. A copy of COUNTY’s Revised RFSQ No. 20-052 and
CONTRACTOR(S)’ Response thereto shall be retained and made available during the term of this
Agreement by COUNTY’s DBH.
Exhibit A List of Contractor(s)
Exhibit B Department of Behavioral Health Guiding Principles of Care
Delivery
Exhibit C-1, et. seq Contractor(s) Service Rates
Exhibit D Fresno County Mental Health Plan Compliance Plan and Code of
Ethics
Exhibit E State Mental Health Requirements
Exhibit F Fresno County Mental Health Plan Grievance and Appeals
Process
Exhibit G Protocol for Completion of Incident Report
Exhibit H National Standards on Culturally and Linguistically Appropriate
Services
Exhibit I Disclosure of Ownership
Exhibit J Certification of Debarment
Exhibit K Self-Dealing Transaction Disclosure Form
///
///
///
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
year first hereinabove written.
COUNTY OF FRESNO
Gary E. Cornuelle
Purchasing Manager
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
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CONTRACTOR
K&L CLINICAL FORENSIC PRACTICE
(Authorized Signature)
Print Name
Title (Chairman of Board, or President, or
CEO)
(Authorized Signature)
Print Name
Title (Secretary of Corporation, or Chief
Financial Officer/Treasurer, or any
Assistant Secretary or Treasurer)
MAILING ADDRESS:
K&L Clinical Forensic Practice
3447 W Shaw Ave, Ste. 102
Fresno, CA 93711
Contact: Tamar M. Kenworthy, PsyD
Phone: (415) 737-9593
FOR ACCOUNTING USE ONLY:
Fund/Subclass: 0001/10000
Organization: 56302175
Account/Program: 7295/0
Tamar M Kenworthy, PsyD
Partner
Vanessa Leite, PhD
Partner
Exhibit A
Page 1 of 1
PSYCHOLOGICAL EVALUATION SERVICES
LIST OF CONTRACTOR(S)
1. K&L Clinical Forensic Practice
Business Type: General Partnership
Business Address: 3447 W. Shaw Avenue, Suite 102
Fresno, Ca 93711
Contact: Tamar Kenworth, Partner
Vanessa Leite, Partner
Service Address: 3447 W. Shaw Avenue, Suite 102
Fresno, Ca 93711
Services: LPS Conservatorship Evaluation
Adult IST Placement Evaluation
Youth IST Placement Evaluation
2. Additional Contractor(s)
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
1
rev 01-02-2020
DBH VISION:
Health and well-being for our community.
DBH MISSION:
DBH, in partnership with our diverse community, is dedicated to providing quality, culturally
responsive, behavioral health services to promote wellness, recovery, and resiliency for
individuals and families in our community.
DBH GOALS:
Quadruple Aim
•Deliver quality care
•Maximize resources while focusing on efficiency
•Provide an excellent care experience
•Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit B
Page 1 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2
rev 01-02-2020
2.Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3.Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4.Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5.Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and values and preferences of those we serve
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit B
Page 2 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
3
rev 01-02-2020
6.Principle Six - Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7.Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8.Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9.Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the person’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit B
Page 3 of 4
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
4
rev 01-02-2020
10.Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11.Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit B
Page 4 of 4
Exhibit C-1
Page 1 of 1
Fresno County Department of Behavioral Health
Psychological Evaluation
Rates of Reimbursement
K&L Clinical Forensic Practice
Service Rates
LPS Conservatorship Evaluation $150/hour
IST Evaluation – Adults $150/hour
IST Evaluation – Youths $150/hour
Exhibit D
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(S) shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, CONTRACTOR(S), CONTRACTOR(S)’ employees and
subcontractors 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.
Exhibit D
Page 2 of 3
7.Bill only for eligible services actually rendered and fully documented. Use billing codes
that accurately describe the services provided.
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(S) may report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or
guideline.
11.Immediately notify the Compliance Officer if they become or may become an Ineligible
person and therefore excluded from participation in the Federal Health Care Programs.
Exhibit D
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature: _______________________________ Date: ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): ______________________________________
Employee Name (print): _______________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:_________________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _______________________________ Date: ___/____/___
Exhibit E
Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1.CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2.PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business
and Professions and Welfare and Institutions Codes.
3.CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with all
State of California and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements at 42, Code
of Federal Regulations sections 2.1 et seq; California Welfare and Institutions
Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the
California Health and Safety Code; Title 22, California Code of Regulations,
section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code.
4.NON-DISCRIMINATION
A.Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B.Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates
of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment.
Exhibit E
Page 2 of 6
C.Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all further
funds, until CONTRACTOR can show clear and convincing evidence to
the satisfaction of COUNTY that funds provided under this Agreement
were not used in connection with the alleged discrimination.
D.Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5.PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1.STATEMENT OF COMPLIANCE: CONTRACTOR has, unless exempted,
complied with the non-discrimination program requirements. (Gov. Code§ 12990
(a-f) and CCR, Title 2, Section 111 02) (Not applicable to public entities.)
2.DRUG-FREE WORKPLACE REQUIREMENTS: CONTRACTOR will comply
with the requirements of the Drug-Free Workplace Act of 1990 and will provide a
drug-free workplace by taking the following actions:
a.Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is
prohibited and specifying actions to be taken against employees for
violations.
b.Establish a Drug-Free Awareness Program to inform employees about:
1)the dangers of drug abuse in the workplace;
2)the person's or organization's policy of maintaining a drug-free
workplace;
3)any available counseling, rehabilitation and employee assistance
programs; and,
4)penalties that may be imposed upon employees for drug abuse
violations.
c.Every employee who works on this Agreement will:
1)receive a copy of the company's drug-free workplace policy
statement; and,
2)agree to abide by the terms of the company's statement as a
condition of employment on this Agreement.
Failure to comply with these requirements may result in suspension of payments
under this Agreement or termination of this Agreement or both and
Exhibit E
Page 3 of 6
CONTRACTOR may be ineligible for award of any future State agreements if the
department determines that any of the following has occurred: the
CONTRACTOR has made false certification, or violated the certification by failing
to carry out the requirements as noted above. (Gov. Code §8350 et seq.)
3.NATIONAL LABOR RELATIONS BOARD CERTIFICATION: CONTRACTOR
certifies that no more than one (1) final unappealable finding of contempt of court
by a Federal court has been issued against CONTRACTOR within the
immediately preceding two (2) year period because of CONTRACTOR’s failure to
comply with an order of a Federal court, which orders CONTRACTOR to comply
with an order of the National Labor Relations Board. (Pub. Contract Code
§10296) (Not applicable to public entities.)
4.CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: CONTRACTOR hereby certifies that CONTRACTOR will
comply with the requirements of Section 6072 of the Business and Professions
Code, effective January 1, 2003.
CONTRACTOR agrees to make a good faith effort to provide a minimum number
of hours of pro bono legal services during each year of the contract equal to the
lessor of 30 multiplied by the number of full time attorneys in the firm’s offices in
the State, with the number of hours prorated on an actual day basis for any
contract period of less than a full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state
contract for legal services, and may be taken into account when determining the
award of future contracts with the State for legal services.
5.EXPATRIATE CORPORATIONS: CONTRACTOR hereby declares that it is not
an expatriate corporation or subsidiary of an expatriate corporation within the
meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to
contract with the State of California.
6.SWEATFREE CODE OF CONDUCT:
a.All CONTRACTORS contracting for the procurement or laundering of
apparel, garments or corresponding accessories, or the procurement of
equipment, materials, or supplies, other than procurement related to a
public works contract, declare under penalty of perjury that no apparel,
garments or corresponding accessories, equipment, materials, or
supplies furnished to the state pursuant to the contract have been
laundered or produced in whole or in part by sweatshop labor, forced
labor, convict labor, indentured labor under penal sanction, abusive forms
of child labor or exploitation of children in sweatshop labor, or with the
benefit of sweatshop labor, forced labor, convict labor, indentured labor
under penal sanction, abusive forms of child labor or exploitation of
children in sweatshop labor. CONTRACTOR further declares under
penalty of perjury that they adhere to the Sweatfree Code of Conduct as
set forth on the California Department of Industrial Relations website
located at www.dir.ca.gov, and Public Contract Code Section 6108.
Exhibit E
Page 4 of 6
b.CONTRACTOR agrees to cooperate fully in providing reasonable access
to the CONTRACTOR’s records, documents, agents or employees, or
premises if reasonably required by authorized officials of the contracting
agency, the Department of Industrial Relations, or the Department of
Justice to determine the contractor’s compliance with the requirements
under paragraph (a).
7.DOMESTIC PARTNERS: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.3.
8.GENDER IDENTITY: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1.CONFLICT OF INTEREST: CONTRACTOR needs to be aware of the following
provisions regarding current or former state employees. If CONTRACTOR has
any questions on the status of any person rendering services or involved with this
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
a).No officer or employee shall engage in any employment, activity or
enterprise from which the officer or employee receives compensation or
has a financial interest and which is sponsored or funded by any state
agency, unless the employment, activity or enterprise is required as a
condition of regular state employment.
b).No officer or employee shall contract on his or her own behalf as an
independent contractor with any state agency to provide goods or
services.
Former State Employees (Pub. Contract Code §10411):
a).For the two (2) year period from the date he or she left state employment,
no former state officer or employee may enter into a contract in which he
or she engaged in any of the negotiations, transactions, planning,
arrangements or any part of the decision-making process relevant to the
contract while employed in any capacity by any state agency.
b).For the twelve (12) month period from the date he or she left state
employment, no former state officer or employee may enter into a
contract with any state agency if he or she was employed by that state
agency in a policy-making position in the same general subject area as
Exhibit E
Page 5 of 6
the proposed contract within the twelve (12) month period prior to his or
her leaving state service.
If CONTRACTOR violates any provisions of above paragraphs, such action by
CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not
receive payment other than payment of each meeting of the board or
commission, payment for preparatory time and payment for per diem. (Pub.
Contract Code §10430 (e))
2.LABOR CODE/WORKERS' COMPENSATION: CONTRACTOR needs to be
aware of the provisions which require every employer to be insured against
liability for Worker's Compensation or to undertake self-insurance in accordance
with the provisions, and CONTRACTOR affirms to comply with such provisions
before commencing the performance of the work of this Agreement. (Labor Code
Section 3700)
3.AMERICANS WITH DISABILITIES ACT: CONTRACTOR assures the State that
it complies with the Americans with Disabilities Act (ADA) of 1990, which
prohibits discrimination on the basis of disability, as well as all applicable
regulations and guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4.CONTRACTOR NAME CHANGE: An amendment is required to change the
CONTRACTOR’s name as listed on this Agreement. Upon receipt of legal
documentation of the name change the State will process the amendment.
Payment of invoices presented with a new name cannot be paid prior to approval
of said amendment.
5.CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a.When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the CONTRACTOR is currently
qualified to do business in California in order to ensure that all obligations
due to the state are fulfilled.
b."Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit.
Although there are some statutory exceptions to taxation, rarely will a
corporate contractor performing within the state not be subject to the
franchise tax.
c.Both domestic and foreign corporations (those incorporated outside of
California) must be in good standing in order to be qualified to do
business in California. Agencies will determine whether a corporation is
in good standing by calling the Office of the Secretary of State.
6.RESOLUTION: A county, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local
governing body, which by law has authority to enter into an agreement,
authorizing execution of the agreement.
Exhibit E
Page 6 of 6
7.AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
CONTRACTOR shall not be: (1) in violation of any order or resolution not
subject to review promulgated by the State Air Resources Board or an air
pollution control district; (2) subject to cease and desist order not subject to
review issued pursuant to Section 13301 of the Water Code for violation of waste
discharge requirements or discharge prohibitions; or (3) finally determined to be
in violation of provisions of federal law relating to air or water pollution.
8.PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
9.INSPECTION and Audit of Records and access to Facilities.
The State, CMS, the Office of the Inspector General, the Comptroller General,
and their designees may, at any time, inspect and audit any records or
documents of CONTRACTOR or its subcontractors, and may, at any time,
inspect the premises, physical facilities, and equipment where Medicaid-related
activities or work is conducted. The right to audit under this section exists for ten
(10)years from the final date of the contract period or from the date of
completion of any audit, whichever is later.
Federal database checks.
Consistent with the requirements at § 455.436 of this chapter, the State must
confirm the identity and determine the exclusion status of CONTRACTOR, any
subcontractor, as well as any person with an ownership or control interest, or
who is an agent or managing employee of CONTRACTOR through routine
checks of Federal databases. This includes the Social Security Administration's
Death Master File, the National Plan and Provider Enumeration System
(NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award
Management (SAM), and any other databases as the State or Secretary may
prescribe. These databases must be consulted upon contracting and no less
frequently than monthly thereafter. If the State finds a party that is excluded, it
must promptly notify the CONTRACTOR and take action consistent with §
438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under
this part is not located outside of the United States and that no claims paid by a
CONTRACTOR to a network provider, out-of-network provider, subcontractor or
financial institution located outside of the U.S. are considered in the development
of actuarially sound capitation rates.
Exhibit F
Page 1 of 2
FRESNO COUNTY MENTAL HEALTH PLAN
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance and
appeal process and an expedited appeal process to resolve grievances and disputes at
the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-for-service
providers give verbal and written information to Medi-Cal beneficiaries regarding the
following:
•How to access specialty mental health services
•How to file a grievance about services
•How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance
form, an appeal form, and Request for Change of Provider Form. All of these
beneficiary materials must be posted in prominent locations where Medi-Cal
beneficiaries receive outpatient specialty mental health services, including the waiting
rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required to give
the individuals served copies of all current beneficiary information annually at the time
their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without any
penalty, change in mental health services, or any form of retaliation. All Medi-Cal
beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written
request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800)654-3937 (for more information)
(559)488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other complaints and
concerns.
Informal provider problem resolution process – the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
Exhibit F
Page 2 of 2
The PRS will attempt to settle the complaint or concern with the provider. If the attempt
is unsuccessful and the provider chooses to forego the informal grievance process, the
provider will be advised to file a written complaint to the MHP address (listed above).
Formal provider appeal process – the provider has the right to access the provider
appeal process at any time before, during, or after the provider problem resolution
process has begun, when the complaint concerns a denied or modified request for MHP
payment authorization, or the process or payment of a provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified request
for payment authorization or a dispute with the MHP regarding the processing or
payment of a provider’s claim to the MHP. The written appeal must be submitted to the
MHP within 90 calendar days of the date of the receipt of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the decision
that addresses each issue raised by the provider, and any action required by the
provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request, the
MHP utilizes a Managed Care staff who was not involved in the initial denial or
modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be asked to
submit a revised request for payment within 30 calendar days of receipt of the decision
Other complaints – if there are other issues or complaints, which are not related to
payment authorization issues, providers are encouraged to send a letter of complaint to
the MHP. The provider will receive a written response from the MHP within 60 calendar
days of receipt of the complaint. The decision rendered buy the MHP is final.
INCIDENT REPORTING
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
The Incident Report must be completed for all incidents involving individuals served through
DBH’s current incident reporting portal, Logic Manager, at
https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcd5072bb1864cdee
4d3d6e
•The reporting portal is available 24 hours a day, every day.
•Any employee of the CONTRACTOR can submit an incident using the reporting
portal at any time. No login is required.
•The designated administrator of the CONTRACTOR can add information to the
follow up section of the report after submission.
•When an employee submits an incident within 24 hours from the time of the incident
or first knowledge of the incident, the CONTRACTOR’s designated administrator, the
assigned contract analyst and the Incident Reporting email inbox will be notified
immediately via email from the Logic Manager system that there is a new incident to
review.
•Meeting the 24 hour incident reporting requirements will be easier as there are no
signatures to collect.
•The user guide attached identifies the reporting process and the reviewer process,
and is subject to updates based on DBH’s selected incident reporting portal system.
Questions about incident reporting, how to use the incident reporting portal, or
designating/changing the name of the administrator who will review incidents for the
CONTRACTOR should be emailed to DBHIncidentReporting@fresnocountyca.gov and the
assigned contract analyst.
Exhibit G
Page 1 of 9
INCIDENT REVIEWER ROLE – User Guide
Fresno County Department of Behavioral Health (DBH) requires all of its county-operated and contracted
providers (through the Mental Health Plan (MHP) and Substance Use Disorder (SUD) services) to complete
a written report of any incidents compromising the health and safety of persons served, employees, or
community members.
Yes! Incident reports will now be made through an on online reporting portal hosted by Logic Manager. It’s
an easier way for any employee to report an incident at any time. A few highlights:
•No supervisor signature is immediately required.
•Additional information can be added to the report by the program supervisor/manager without
having to resubmit the incident.
•When an incident is submitted, the assigned contract analyst, program supervisor/manager,
clinical supervisor and the DBHIncidentReporting mailbox automatically receives an email
notification of a new incident and can log in any time to review the incident. Everything that
was on the original paper/electronic form matches the online form.
•Do away with submitting a paper version with a signature.
•This online submission allows for timely action for the health and safety of the persons-served,
as well as compliance with state reporting timelines when necessary.
As an Incident Reviewer, the responsibility is to:
•Log in to Logic Manager and review incident submitted within 48 hours of notification of incident.
•Review incident for clarity, missing information and add in additional information deemed
appropriate.
•Notify DBHIncidentReporting@fresnocountyca.gov if there is additional information to be report
after initial submission
•Contact DBHIncidentReporting@fresnocountyca.gov if there are any concerns, questions or
comments with Logic Manager or incident reporting.
Below is the link to report incidents
https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcd5072bb1864cdee4d3d6e
The link will take employees to the reporting screen to begin incident submission:
Mental Health Plan (MHP) and Substance Use Disorder (SUD) services
Incident Reporting System
Exhibit G
Page 2 of 9
Exhibit G
Page 3 of 9
Similar to the paper version, multiple incident categories can be selected
Exhibit G
Page 4 of 9
As another bonus feature, either drag files (such as a copy of a UOR, additional statements/document) or click on
Add File to upload a file.
Similar to the paper version, multiple Action Taken categories can be selected.
When done entering all the information, simply click submit.
Any fields that have a red asterisk, require information and will prevent submission of the form if left blank.
A “Thank you for your submission” statement will pop up if an incident is successfully submitted. Click “Reload the
Form” to submit another incident.
Exhibit G
Page 5 of 9
A Notification email will be received when a new incident is reported, or a new comment has been made regarding
an incident. Click on “Open this incident in Logic Manager” and the Logic Manager login screen will show.
Enter in email address and password. First time users will be prompted to set up a password.
Exhibit G
Page 6 of 9
Once logged in, the main screen will show reviewer task (incidents to review). Click on analyst/supervisor follow up
to view the incident.
This screen below will then pop up. There are 5 tabs to navigate through. Client information will show the client and
facility information. No edits can be made to this section.
The next tab is Summary: No edits can be made to this section.
Exhibit G
Page 7 of 9
The next tab is Follow up: This section can be edited. Add to the areas below or make corrections to these fields. Be
sure to click SAVE when edits are made. Then Cancel to Exit out of the incident.
The next tab is Documents: View and add attachments to the incident. Be sure to click SAVE when adding
documents. Then Cancel to Exit out of the incident.
If all tasks are followed up with and the incident no longer needs further review/information, click SUBMIT. Once
submitted, the incident will be removed from the task list and no further edits can be made. Notice the SUBMIT
button is on every tab. If further information needs to be included, email
DBHIncidentReporting@fresnocountyca.gov
Exhibit G
Page 8 of 9
To get back to the home view, click on the Logic Manager icon at any time. Any incidents that still need review will
show on this screen, click on the next incident and start the review process again.
Exhibit G
Page 9 of 9
1
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help
eliminate health care disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1.Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and
practices, preferred languages, health literacy, and other communication needs.
Governance, Leadership, and Workforce:
2.Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and
allocated resources.
3.Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in
the service area.
4.Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance:
5.Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate
timely access to all health care and services.
6.Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
7.Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters
should be avoided.
8.Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Engagement, Continuous Improvement, and Accountability:
9.Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s
planning and operations.
10.Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous
quality improvement activities.
11.Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to
inform service delivery.
12.Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the
cultural and linguistic diversity of populations in the service area.
13.Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
14.Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts
or complaints.
15.Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.
Think Cultural Health
https://www.thinkculturalhealth.hhs.gov/
contact@thinkculturalhealth.hhs.gov
Exhibit H
Page 1 of 2
2
The Case for the National CLAS Standards
Health equity is the attainment of the highest level of health for all people.1 Currently, individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of health, or those conditions in which
individuals are born, grow, live, work, and age,2 such as socioeconomic status, education level, and the availability of health services.3
Though health inequities are directly related to the existence of historical and current discrimination
and social injustice, one of the most modifiable factors is the lack of culturally and linguistically
appropriate services, broadly defined as care and services that are respectful of and responsive to
the cultural and linguistic needs of all individuals.
Health inequities result in disparities that directly affect the quality of life for all individuals. Health
disparities adversely affect neighborhoods, communities, and the broader society, thus making
the issue not only an individual concern but also a public health concern. In the United States, it
has been estimated that the combined cost of health disparities and subsequent deaths due to
inadequate and/or inequitable care is $1.24 trillion.4
Culturally and linguistically appropriate services are increasingly recognized as effective in improving
the quality of care and services.5,6 By providing a structure to implement culturally and linguistically
appropriate services, the National CLAS Standards will improve an organization’s ability to address
health care disparities.
The National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities7 and the National Stakeholder Strategy for
Achieving Health Equity,8 which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial
and ethnic health disparities across the country.
Similar to these initiatives, the National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities
by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. Adoption of
these Standards will help advance better health and health care in the United States.
Of all the forms of
inequality, injustice in
health care is the most
shocking and inhumane.
— Dr. Martin Luther King, Jr.
Bibliography
1. U.S. Department of Health and Human Services, Office of Minority Health (2011). National Partnership for Action to End Health Disparities. Retrieved from http://minorityhealth.hhs.gov/npa
2. World Health Organization. (2012). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/
3. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy people 2020: Social determinants of health. Retrieved from http://www.
healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39
4. LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Retrieved from the Joint Center for Political and Economic Studies website: http://www.
jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2 0Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf
5. Beach, M. C., Cooper, L. A., Robinson, K. A., Price, E. G., Gary, T. L., Jenckes, M. W., Powe, N.R. (2004). Strategies for improving minority healthcare quality. (AHRQ Publication No. 04-E008-02). Retrieved
from the Agency of Healthcare Research and Quality website: http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf
6. Goode, T. D., Dunne, M. C., & Bronheim, S. M. (2006). The evidence base for cultural and linguistic competency in health care. (Commonwealth Fund Publication No. 962). Retrieved from The
Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf
7. U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care. Retrieved from http://
minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
8. National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for achieving health equity. Retrieved from U.S. Department of Health and Human Services, Office of
Minority Health website: http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
Think Cultural Health
https://www.thinkculturalhealth.hhs.gov/
contact@thinkculturalhealth.hhs.gov
Exhibit H
Page 2 of 2
Exhibit I
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I.Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II.Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A.Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? .........................................................................................................................❒ ❒
B.Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ......................................................................................❒ ❒
C.Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ...........❒ ❒
III.A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B.Type of entity: ❒ Sole proprietorship ❒Partnership ❒Corporation❒Unincorporated Associations ❒Other (specify)
C.If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D.Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit I
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? .......................................................❒ ❒
If yes, give date.
B.Do you anticipate any change of ownership or control within the year?.......................................................❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................❒ ❒
If yes, when?
V.Is the facility operated by a management company or leased in whole or part by another organization?..........❒ ❒
If yes, give date of change in operations.
VI.Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?.........❒ ❒
VII.A. Is this facility chain affiliated? ......................................................................................................................❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B.If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed)Title
Signature Date
Remarks
Exhibit J
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1.By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
2.The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant shall
submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3.The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
4.The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5.The terms covered transaction, debarred, suspended, ineligible, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this
clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which
this proposal is being submitted for assistance in obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
CERTIFICATION
(1)The prospective primary participant certifies to the best of its knowledge and belief, that it,
its owners, officers, corporate managers and partners:
(a)Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any Federal department or agency;
(b)Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State
or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
Exhibit J
Page 2 of 2
(c)Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2)Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Signature:Date:
(Printed Name & Title)(Name of Agency or Company)
Exhibit K
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “COUNTY”),
members of a CONTRACTOR’s board of directors (hereinafter referred to as “County
Contractor”), must disclose any self-dealing transactions that they are a party to while
providing goods, performing services, or both for the COUNTY. A self-dealing transaction is
defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member’s name, job title (if applicable), and date this disclosure is being
made.
(2)Enter the board member’s company/agency name and address.
(3)Describe in detail the nature of the self-dealing transaction that is being disclosed to
the COUNTY. At a minimum, include a description of the following:
a.The name of the agency/company with which the corporation has the
transaction; and
b.The nature of the material financial interest in the corporation’s transaction that
the board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5)Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit K
Page 2 of 2
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3)Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5)Authorized Signature
Signature: Date: