HomeMy WebLinkAboutAgreement A-20-492 with RH Community Builders.pdf1
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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, RH Community Builders LP, a limited California partnership, whose
address is 352 Bedford Ave., Suite 110, Fresno, CA, 93711, hereinafter referred to as “CONTRACTOR,”
collectively, “the parties.”
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), recognizes the need
for a qualified agency to provide short-term lodging driven by peer support services to individuals who
have a severe mental illness (SMI), are currently homeless, or at-risk of homelessness, are eligible for
DBH Services, and have not previously engaged in ongoing outpatient behavioral health services;
WHEREAS, COUNTY, through its DBH, is a Mental Health Plan (MHP) as defined in Title 9 of the
California Code of Regulations (C.C.R.), section 1810.226; and
WHEREAS, CONTRACTOR is qualified and willing to operate said short-term lodging pursuant to
the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto
agree as follows:
1.SERVICES
A.CONTRACTOR shall perform all services and fulfill all responsibilities as set forth in
Exhibit A, attached hereto and by this reference incorporated herein and made part of this Agreement.
B.CONTRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 20-034 dated January 21, 2020, Addendum No.
One (1) to COUNTY’s RFP No. 20-034 dated January 24, 2020, and Addendum No. Two (2) to
COUNTY’s RFP No. 20-034 dated February 14, 2020 and CONTRACTOR’s response to said Revised
RFP dated February 24, 2020 all incorporated herein by reference and made part of this Agreement. In
the event of any inconsistency among these documents, the inconsistency shall be resolved by giving
precedence in the following order of priority: 1) to this Agreement, including all Exhibits; 2) to the Revised
RFP; and 3) to the Response to the Revised RFP. A copy of COUNTY’s Revised RFP No. 20-034 and
15th December
Agreement No. 20-492
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CONTRACTOR’s response thereto shall be retained and made available during the term of this
Agreement by COUNTY’s DBH Contracts Division.
C.It is acknowledged by all parties hereto that COUNTY's DBH shall monitor the
services provided by CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement.
D.CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
consisting of staff from COUNTY's DBH to discuss service requirements, data reporting, training, policies
and procedures, overall program operations and any problems or foreseeable problems that may arise.
E.CONTRACTOR shall maintain requirements as an organizational provider
throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement. If for
any reason, this status is not maintained, COUNTY may terminate this Agreement pursuant to Section
Three (3) of this Agreement.
F.CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, it shall have appropriate staff hired and in place for program services and
operations, or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate this
Agreement, in accordance with Section Three (3) of this Agreement.
G.It is acknowledged by all parties hereto that the ramp up period shall commence on
October 20, 2020. Due to pending timelines with renovations and site certification, the dates of the ramp
up period and initial operational period may be adjusted with the written approval of CONTRACTOR and
COUNTY’s DBH Director, or designee.
H.Any change to CONTRACTOR’s location of the service site may be made only
upon sixty (60) days advance written notification to COUNTY’s DBH Director and upon written approval
from the COUNTY’s DBH Director or designee.
2.TERM
This Agreement shall become effective on the 20th day of October, 2020 and shall
terminate on the 30th day of June, 2021.
Effective July 1, 2021, this Agreement, subject to satisfactory outcomes performance and
subject to State funding each year, shall continue for an additional two (2) year term upon the same terms
and conditions herein set forth, unless written notice of non-renewal is given by COUNTY, CONTRACTOR
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or COUNTY’s DBH Director or designee, not later than sixty (60) days prior to the close of the then current
Agreement term.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified as agreed upon by
CONTRACTOR, or this Agreement terminated at any time by giving CONTRACTOR, in either event with
sixty (60) days advance written notice.
B. Breach of Contract – Subject to the Cure Rights set forth herein, 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.
Prior to suspending or terminating the Agreement for a breach of contract (except in the event of an illegal
use of funds), COUNTY shall provide written notice to CONTRACTOR of the breach and allow thirty (30)
days for the Contractor to cure such breach, provided, however, that if the nature of the CONTRACTOR
cure is such that more than thirty (30) days are reasonably required for its performance, then
CONTRACTOR shall not be in breach if performance is commenced within such thirty (30) day period and
thereafter diligently pursues to completion.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any breach
of this Agreement or any default which may then exist on the part of CONTRACTOR. Neither shall such
payment impair or prejudice any remedy available to COUNTY with respect to the breach or default. The
COUNTY shall have the right to demand of the CONTRACTOR the repayment to the COUNTY of any
funds disbursed to CONTRACTOR under this Agreement, which in the reasonable judgment of COUNTY
were illegally or improperly used. The CONTRACTOR shall promptly refund any such funds upon demand
or at COUNTY’s option such repayment shall be deducted from future payments owing to CONTRACTOR
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under this Agreement.
C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY, COUNTY’s DBH Director or designee, or CONTRACTOR
upon the giving of sixty (60) days advance written notice of an intention to terminate, with notice to the
COUNTY or CONTRACTOR, as applicable.
4.COMPENSATION
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation in accordance with the budget set forth in Exhibit B, attached hereto and by this reference
incorporated herein and made part of this Agreement.
A.Maximum Contract Amount
The maximum amount payable to CONTRACTOR for the ramp-up period of
October 20, 2020 through January 31, 2021 shall not exceed Five Hundred Thirteen Thousand Eight
Hundred Sixteen and No/100 Dollars ($513,816.00).
The maximum amount payable to CONTRACTOR for the initial operational period
of February 1, 2021 through June 30, 2021 shall not exceed Seven Hundred Thirty-Three Thousand
Three Hundred Forty-Three and No/100 Dollars ($733,343.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2021
through June 30, 2022 shall not exceed One Million Seven Hundred Two Thousand Eight Hundred
Thirty-Two and No/100 Dollars ($1,702,832.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2022
through June 30, 2023 shall not exceed One Million Seven Hundred Twenty-Nine Thousand Two
Hundred Twenty-Five and No/100 Dollars ($1,729,225.00).
In no event shall the maximum contract amount for all the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess of Four
Million Six Hundred Seventy-Nine Thousand Two Hundred Sixteen and No/100 Dollars ($4,679,216.00)
during the total term of this Agreement.
Payment shall be made upon certification or other proof satisfactory to COUNTY’s
DBH that services have actually been performed by CONTRACTOR as specified in this Agreement.
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B.Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the Federal Internal
Revenue Services (IRS) published rate.
C.Other than travel reimbursement, it is understood that all expenses incidental to
CONTRACTOR’s performance of services under this Agreement shall be borne by CONTRACTOR. If
CONTRACTOR fails to comply with any provision of this Agreement, and fails to cure as provided in
Section 3(b) and COUNTY terminates this AGREEMENT, COUNTY shall be relieved of its obligation for
further compensation.
D.Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt by COUNTY of the
monthly invoicing as described in Section Five (5) herein. Payments shall be made after receipt and
verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as identified in
Exhibit B, in the performance of this Agreement and shall be documented to COUNTY on a monthly basis
by the tenth (10th) of the month following the month of said expenditures. The parties acknowledge that
the CONTRACTOR will be performing hiring, training, and credentialing of staff, and the COUNTY will be
performing additional staff credentialing to ensure compliance with State and Federal regulations.
E.COUNTY shall not be obligated to make any payments under this Agreement if the
request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
All final invoices shall be submitted by CONTRACTOR within sixty (60) days
following the final month of service for which payment is claimed. No action shall be taken by COUNTY on
invoices submitted beyond the sixty (60) day closeout period. Any compensation which is not expended
by CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
COUNTY.
F.The services provided by CONTRACTOR under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by the
State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred payment
shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The period of
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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.
G.CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions that become final and due to CONTRACTOR’s deficiency discovered
through the State audit process and COUNTY utilization review during the course of this Agreement. At
COUNTY’s election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon
notification or shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not
receive reimbursement for any units of services rendered that are disallowed or denied by the Fresno
County Mental Health Plan (Mental Health Plan) utilization review process or through the State
Department of Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible
clients. Notwithstanding the above, COUNTY must notify CONTRACTOR prior to any State audit process
and/or COUNTY utilization review. To the extent allowable by law, CONTRACTOR shall have the right to
be present during each phase of any State audit process and/or COUNTY utilization review and shall be
provided all documentation related to each phase of any State audit process and/or COUNTY utilization
review. Additionally, prior to any disallowances/audit exceptions becoming final, CONTRACTOR shall be
given at least 10 business days to respond to such proposed disallowances/audit exceptions.
H.It is understood by CONTRACTOR and COUNTY that this Agreement is funded
with mental health funds to serve adult individuals with Severely Mentally Ill (SMI) disorders, many of
whom have co-occurring substance use disorders. It is further understood by CONTRACTOR and
COUNTY that funds shall be used to support appropriately integrated and documented treatment services
for co-occurring mental health and substance use disorders.
5.INVOICING
A.CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each
month for actual expenses incurred during the prior month electronically to: 1)
dbhinvoicereview@fresnocountyca.gov, 2) dbh-invoices@fresnocountyca.gov; and 3)
dbhcontractedservicesdivision@fresnocountyca.gov with a copy to the assigned COUNTY DBH Staff
Analyst. After CONTRACTOR renders service to referred individuals, CONTRACTOR shall invoice
COUNTY for payment, certify the expenditure, and submit electronic claiming data into COUNTY’s
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electronic information system for all individuals served, including those eligible for Medi-Cal as well as
those that are not eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. Invoices
and reports shall be in such detail as reasonably acceptable to COUNTY’s DBH, as described herein and
in Section Thirteen (13) of this Agreement. No reimbursement for costs incurred by CONTRACTOR for
services delivered under this Agreement shall be made until the invoice and supporting documentation is
received, verified, and approved by COUNTY’s DBH. COUNTY must pay CONTRACTOR before
submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible individuals.
B.If CONTRACTOR chooses to utilize the COUNTY’s electronic health record (EHR)
system (currently AVATAR, the preferred EHR system by DBH) as their own full EHR system, COUNTY’s
DBH shall invoice CONTRACTOR for associated fees as follows:
1)monthly for the EHR system hosting fees;
2)annually for the EHR system maintenance and licensing fees; and
3)annually for EHR system Reaching Recovery module fees
CONTRACTOR shall provide payment for the COUNTY’s EHR system expenditures to
COUNTY’s Fresno County Department of Behavioral Health, Accounts Receivable, P.O. Box 712, Fresno,
CA 93717-0712, Attention: Business Office, within forty-five (45) days after the date of receipt by
CONTRACTOR of the invoicing provided by COUNTY.
C.At the discretion of COUNTY’s DBH Director or designee, if an invoice is incorrect
or is otherwise not in proper form or substance, COUNTY’s DBH Director or designee, shall have the right
to withhold payment as to only that portion of the invoice that is incorrect or improper after five (5) days
prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a period of
ninety (90) days after notification of an incorrect or improper invoice. If after the ninety (90) day period, the
invoice(s) is still not corrected to COUNTY DBH’s reasonable satisfaction, COUNTY’s DBH Director or
designee, may elect to terminate this Agreement, pursuant to the termination provisions stated in Section
Three (3) of this Agreement. In addition, for invoices received ninety (90) days after the expiration of each
term of this Agreement or termination of this Agreement, at the discretion of COUNTY’s DBH Director or
designee, COUNTY’s DBH shall have the right to deny payment of any additional invoices received.
D.CONTRACTOR(S) shall submit monthly invoices and general ledgers to
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COUNTY’s DBH that itemize the line item charges for monthly program costs. Unallowable costs such as
lobbying or political donations must be deducted from the monthly invoice reimbursements. The invoices
and general ledgers will serve as tracking tools to determine if CONTRACTOR’s program costs are in
accordance with its budgeted cost. Failure to submit GL reports and other supporting documentation shall
be deemed sufficient cause for COUNTY to withhold payments until there is compliance, as further
described in Section Five (5) herein.
E.CONTRACTOR must maintain financial records for a period of seven (7) years or
until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for
any disallowances related to the inadequate documentation of CONTRACTOR.
F.CONTRACTOR is responsible for collecting and managing of data in a manner to
be determined by DHCS and COUNTY’s DBH in accordance with applicable rules and regulations.
COUNTY’s EHR system is a critical source of information for purposes of monitoring service volume and
obtaining reimbursement. CONTRACTOR must attend the COUNTY’s DBH training on equipment
reporting for assets, intangible and sensitive minor assets, COUNTY’s EHR system, and related cost
reporting.
G.CONTRACTOR shall submit service data into COUNTY’s EHR system within thirty
(30) calendar days from the date of services were rendered. CONTRACTOR will comply with all applicable
policies, procedures, directives and guidelines regarding the use of COUNTY’s electronic information
system.
H.CONTRACTOR must provide all necessary data to allow 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 EHR system; 2) providing an electronic file compatible with COUNTY’s EHR system; or 3)
integration between COUNTY’s EHR system and CONTRACTOR’s information system.
I.If a client has dual coverage, such as other health coverage (OHC) or Federal
Medicare, CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or have
validation of claiming with no response ninety (90) days after the claim was mailed before the service can
be entered into COUNTY’s EHR system. CONTRACTOR must report all third party collections for
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Medicare, third party, client pay, or private pay in each monthly invoice and in the annual cost report that is
required to be submitted. A copy of explanation of benefits or CMS 1500 form is required as
documentation. CONTRACTOR must report all revenue collected from OHC, third-party, client-pay, or
private-pay in each monthly invoice and in the annual cost report that is required to be submitted.
CONTRACTOR shall submit monthly invoices for reimbursement that equal the amount due
CONTRACTOR less any funding sources not eligible for Federal and State reimbursement.
CONTRACTOR must comply with all laws and regulations governing the Federal Medicare program,
including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2)
the regulation and rules promulgated by the Federal Centers for Medicare and Medicaid Services as they
relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for
CONTRACTOR’s compliance as of the effective date of each Federal, State or local law or regulation
specified.
J.Medi-Cal Certification and Mental Health Plan (MHP) Compliance
CONTRACTOR shall establish and maintain Medi-Cal certification or become
certified within ninety (90) days of the execution of this Agreement through COUNTY’s DBH. In addition,
CONTRACTOR shall work with COUNTY’s DBH to execute the process if not currently certified by
COUNTY for credentialing of staff. Service location must be approved by COUNTY’s DBH during the
Medi-Cal certification process. During this process, the CONTRACTOR shall obtain a legal entity number
established by DHCS as this is a requirement for maintaining COUNTY’s MHP Organizational Provider
status throughout the term of this Agreement. CONTRACTOR shall become Medi-Cal certified prior to
providing services to Medi-Cal eligible clients and seeking reimbursement from the COUNTY.
CONTRACTOR will not be reimbursed by COUNTY for any services rendered prior to Medi-Cal
certification. CONTRACTOR shall comply with any and all requests and directives associated with
COUNTY maintaining State Medi-Cal site certification. CONTRACTOR shall provide specialty mental
health services in accordance with COUNTY’s MHP. CONTRACTOR must comply with the “Fresno
County Mental Health Plan Compliance Program and Code of Conduct” set forth in Exhibit D, attached
hereto and incorporated herein by reference and made part of this Agreement. It is understood that each
service is subject to audit for compliance with Federal and State regulations, and that COUNTY may be
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making payments in advance of said review. In the event that a service is disapproved, COUNTY may, at
its sole discretion, withhold compensation or set off from other payments due the amount of said
disapproved services. CONTRACTOR shall be responsible for audit exceptions to ineligible dates of
services or incorrect application of utilization review requirements. CONTRACTOR shall comply with any
and all requests associated with any State and/or Federal reviews or audits.
M.CONTRACTOR may provide direct specialty mental health services using
unlicensed staff as long as the individual is approved by the COUNTY’s MHP, is supervised by licensed
staff who meet the Board of Behavioral Sciences requirements for supervision, works within his/her scope,
and only delivers allowable direct specialty mental health services. Unlicensed staff must also be
credentialed by COUNTY’s MHP.
6.INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under this
Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’s officers, agents, and employees will at all times be acting and performing as an
independent CONTRACTOR, and shall act in an independent capacity and not as an officer, agent,
servant, employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no
right to control or supervise or direct the manner or method by which CONTRACTOR shall perform its
work and function. However, COUNTY shall retain the right to administer this Agreement so as to verify
that CONTRACTOR is performing their obligations in accordance with the terms and conditions thereof.
CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the
rules and regulations, if any, of governmental authorities having jurisdiction over matters the subject
thereof.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
matters relating to payment of CONTRACTOR’s employees, including compliance with Social Security,
withholding, and all other regulations governing such matters. It is acknowledged that during the term of
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this Agreement, CONTRACTOR may be providing services to others unrelated to COUNTY or to this
Agreement.
7.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent of
all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to services, staffing, and responsibilities of the
CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health treatment, as
set forth in Exhibit A, may be made with the signed written approval of COUNTY’s DBH Director or
designee and CONTRACTOR.
In addition, changes to expense category (i.e., Salary & Benefits, Client Support,
Facilities/Equipment, Operating Expenses, Administrative Expenses, Special Expenses, Fixed Assets,
etc.) subtotals in the budgets, and changes to the volume of units of services/types of service units to be
provided as set forth in Exhibit B, that do not exceed 10% of the maximum compensation payable to the
CONTRACTOR may be made with the written approval of COUNTY’s DBH Director, or designee.
Said modifications shall not result in any change to the annual maximum compensation
amount payable to CONTRACTOR, as stated in this Agreement.
8.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties under
this Agreement without the prior written consent of COUNTY.
9.HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY
in connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents or
employees of covenants and duties under this Agreement, and from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
any person, firm or corporation who may be injured or damaged by the performance, or failure to
perform, of CONTRACTOR, their officers, agents or employees of covenants and duties under this
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Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California audit
exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10.INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any third
parties, CONTRACTOR, at its sole expense, shall maintain in full force and affect the following insurance
policies throughout the term of this Agreement:
A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two MillionDollars ($2,000,000) per occurrence and an annual aggregate of Five MillionDollars ($5,000,000). This policy shall be issued on a per occurrence basis.COUNTY may require specific coverage including completed operations, productliability, contractual liability, Explosion, Collapse, and Underground (XCU), firelegal liability or any other liability insurance deemed reasonably necessarybecause of the nature of the Agreement.
B.Automobile Liability
Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or if Consultant has no
owned autos, Code 8 (hired) and 9 (non-owned).with limits of not less than) One Million Dollars
($1,000,000) per accident for bodily injury and property damage.
C.Professional Liability
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. . The Retroactive Date must be shown, and must be before the date
of the contract or the beginning of contract work. Insurance must be maintained
and evidence of insurance must be provided for at least five (5) years after
completion of the contract of work. If coverage is canceled or non-renewed,
and not replaced with another claims-made policy form with a Retroactive
Date prior to the contract effective date, the Contractor must purchase
“extended reporting” coverage for a minimum of five (5)
D.Child Abuse/Molestation and Social Services Coverage
CONTRACTOR shall have either separate policies or an umbrella policy withendorsements covering Child Abuse/Molestation and Social Services Liabilitycoverage or have a specific endorsement on their General Commercial liabilitypolicy covering Child Abuse/Molestation and Social Services Liability. The policylimits for these policies shall be One Million Dollars ($1,000,000) per occurrence
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with a Two Million Dollars ($2,000,000) annual aggregate. The policies are to be on a per occurrence basis.
E.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by theCalifornia Labor Code.
G.Cyber Liability
Cyber Liability Insurance, with limits not less than $2,000,000 per occurrence or
claim, $2,000,000 aggregate. Coverage shall be sufficiently broad to respond to
duties and obligations undertaken by CONTRACTOR 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. If the
Vendor maintains broader coverage and/or higher limits than the minimums
shown above, the Entity requires and shall be entitled to the broader coverage
and/or the higher limits maintained by the contractor. Any available insurance
proceeds in excess of the specified minimum limits of insurance and coverage
shall be available to the Entity.
H.Waiver of Subrogation
CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogationwhich any insurer of said CONTRACTOR may acquire against the COUNTY byvirtue of the payment of any loss under insurance. CONTRACTOR agrees toobtain any endorsement that may be necessary to affect this waiver ofsubrogation, but this provision applies regardless of whether or not the COUNTYhas received a waiver of subrogation endorsement from the insurer.
I.Additional Requirements Related to InsuranceCONTRACTOR hereby waives its right to recover from COUNTY, its officers,
agents, employees any amounts paid by the policy of worker’s compensation
insurance required by this Agreement. CONTRACTOR 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 subrogation under
and this paragraph is effective whether or not CONTRACTOR obtains such an
endorsement.
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
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additional insured, but only insofar as the operations under this Agreement are concerned. Such coverage
for additional insured shall apply as primary insurance and any other insurance, or self-insurance,
maintained by COUNTY, its officers, agents and employees shall be excess only and not contributing with
insurance provided under CONTRACTOR’s policies herein. This insurance shall not be cancelled or
changed without a minimum of thirty (30) days advance written notice given to COUNTYyears after
completion of work. Within thirty (30) days from the date CONTRACTOR signs this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 3133 N.
Millbrook Ave, Fresno, California, 93703, Attention: Contracts Division, stating that such insurance
coverages have been obtained and are in full force; that the County of Fresno, its officers, agents and
employees will not be responsible for any premiums on the policies; that such Commercial General
Liability insurance names the County of Fresno, its officers, agents and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are concerned;
that such coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents and employees, shall be excess only and not
contributing with insurance provided under CONTRACTOR’s policies herein; and that this insurance shall
not be cancelled or changed without a minimum of thirty (30) days advance, written notice given to
COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement
upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of California.
Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of A FSC VII or
better.
11.LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff shall
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maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for the
provision of the services hereunder and required by the laws and regulations of the United States of
America, State of California, the County of Fresno, and any other applicable governmental agencies.
CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such
licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of any
appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR’s staff shall comply with all
applicable laws, rules or regulations, as may now exist or be hereafter changed.
12.RECORDS
CONTRACTOR shall maintain records in accordance with Exhibit D, "Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part of
this Agreement. COUNTY shall be allowed to review all records of services provided, including the goals
and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
13.REPORTS
A.Outcome Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
reasonably requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to
change at COUNTY’s DBH discretion.
B.Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records, reports,
data, and other information as COUNTY’s DBH may reasonably request pertaining to matters covered by
this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder within a reasonable time after request by the COUNTY’s DBH, it shall be deemed
sufficient cause for COUNTY to withhold monthly payments until there is compliance. In addition,
CONTRACTOR shall provide written notification and explanation to COUNTY within five (5) days of any
funds received from another source to conduct the same services covered by this Agreement.
C.Cost Report
CONTRACTOR shall provide financial data to identify all direct and indirect costs
incurred by the CONTRACTOR for all services delivered under this Agreement. All Cost Reports must be
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prepared in accordance with Generally Accepted Accounting Principles (GAAP) and Welfare and
Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3) and 5718(c). Unallowable costs such as lobbying or
political donations must be deducted on the cost report and monthly invoice reimbursements.
D.Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
agree to settle dollar amounts disallowed or settled in accordance with DHCS audit settlement findings
related to the reimbursement provided under this Agreement. CONTRACTOR will participate in the several
phases of settlements between COUNTY/CONTRACTOR and DHCS. The phases of initial cost reporting
for settlement according to State reconciliation of records for paid Medi-Cal services and audit settlement
are: State DHCS audit 1) initial cost reporting - after an internal review by COUNTY, the COUNTY files the
cost report with State DHCS on behalf of the CONTRACTOR’s legal entity for the fiscal year; 2) Settlement
–State reconciliation of records for paid Medi-Cal services, approximately 18 to 36 months following the
State close of the fiscal year, DHCS will send notice for any settlement under this provision to the
COUNTY; 3) Audit Settlement-State DHCS audit. After final reconciliation and settlement DHCS may
conduct a review of medical records, cost report along with support documents submitted to COUNTY in
initial submission to determine accuracy and may disallow costs and/or units of services. COUNTY may
choose to appeal and therefore reserves the right to defer payback settlement with CONTRACTOR until
resolution of the appeal. DHCS Audits will follow Federal Medicaid procedures for managing
overpayments. If at the end of the Audit Settlement, the COUNTY reasonably determines that it overpaid
the CONTRACTOR based on objective finding of the DHCS, it will require the CONTRACTOR to repay the
Medi-Cal related overpayment back to the COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification by the
COUNTY, or COUNTY shall withhold future payments until all excess funds have been recouped by
means of an offset against any payments then or thereafter owing to COUNTY under this or any other
Agreement between the COUNTY and CONTRACTOR.
14.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and the
State Department of Health Care Services, or their designees, the right to review and monitor records,
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services or procedures, at any time, in regard to clients, as well as the overall operation of
CONTRACTOR’s performance, in order to ensure compliance with the terms and conditions of this
Agreement.
15.REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended during
the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of
such amendment.
16.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department Health Care Services, and that under said agreement
the State imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall adhere
to all State requirements applicable to CONTRACTOR’s services, including those identified in Exhibit E
“State Mental Health Requirements”, attached hereto and by this reference incorporated herein and made
part of this Agreement. CONTRACTOR shall also file an incident report for all incidents involving clients,
following the Protocol and using the Worksheet identified in Exhibit F, attached hereto and by this
reference incorporated herein and made part of this Agreement or a protocol and worksheet presented by
CONTRACTOR that is accepted by COUNTY’s DBH Director or his or her designee.
17.COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health
Plan as described in Exhibit G, attached hereto and by this reference incorporated herein and made part of
this Agreement.
18.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
19.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
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191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is only for treatment,
payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder
by the U.S. Department of Health and Human Services (HIPAA Regulations) and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as
set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504€ of the Code of
Federal Regulations.
20.DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into
a contractual relationship with the COUNTY for the purpose of providing services under this Agreement
must employ adequate data security measures to protect the confidential information provided to
CONTRACTOR by the COUNTY, including but not limited to the following:
A.CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1)CONTRACTOR has received authorization by COUNTY for telecommuting
purposes;
2)Current virus protection software is in place;
3)Mobile device has the remote wipe feature enabled; and
4)A secure connection is used.
B.CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
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peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief Information
Officer, and/or his or her designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure connection.
Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on non-
COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer, and/or his or
her designee(s).
D.CONTRACTOR may not store COUNTY’s private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E.CONTRACTOR shall be responsible to employ strict controls to ensure the integrity
and security of COUNTY’s confidential information and to prevent unauthorized access, viewing, use or
disclosure of data maintained in computer files, program documentation, data processing systems, data
files and data processing equipment which stores or processes COUNTY data internally and externally.
F.Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
BIT or higher. Additionally, a password or pass phrase must be utilized.
G.CONTRACTOR is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data maintained
in computer files, program documentation, data processing systems, data files and data processing
equipment which stores or processes COUNTY data internally or externally.
H.COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information provided to
CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as
required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be
responsible for all costs incurred as a result of providing the required notification.
21.PROPERTY OF COUNTY
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A.COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items will
be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1)Asset must have life span of over one year.
2)The asset is not a repair part
3)The asset must be valued at or greater than the capitalization thresholds for
the asset type
Asset type Threshold
•land $0 •buildings and improvements $100,000
•infrastructure $100,000 •be tangible $5,000 o equipmentovehicles
•or intangible asset $100,000 o Internally generated softwareoPurchased softwareoEasementsoPatents
•capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed asset log
will be maintained by COUNTY’s Asset Management System and annual inventoried until the asset is fully
depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be inventoried in
comparison to COUNTY’s DBH Asset Inventory System.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are sensitive
assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and other sensitive
items as determined by COUNTY’s DBH Director or designee. CONTRACTOR maintains a tracking
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system on the items and are not required to be capitalize or depreciated. The items are subject to annual
inventory for compliance.
C.Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in an
annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of this
Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are returned to
COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY owned
undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1)To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2)To label all items of equipment with COUNTY assigned program number, to
perform periodic inventories as required by COUNTY and to maintain an inventory list showing where and
how the equipment is being used, in accordance with procedures developed by COUNTY. All such lists
shall be submitted to COUNTY within ten (10) days of any request therefore; and
3)To report in writing to COUNTY immediately after discovery, the lost or theft
of any items of equipment. For stolen items, the local law enforcement agency must be contacted and a
copy of the police report submitted to COUNTY.
D.The purchase of any equipment by CONTRACTOR with funds provided hereunder
shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of this Agreement as
appropriate, and must be directly related to CONTRACTOR’s services or activity under the terms of this
Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from equipment
purchased, which are incurred by CONTRACTOR, if prior written approval has not been obtained from
COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY’s DBH whenever
there is any modification or change in the use of any property acquired or improved, in whole or in part,
using funds under this Agreement. If any real or personal property acquired or improved with said funds
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identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value
of the property, less any portion thereof attributable to expenditures of funds not provided under this
Agreement. These requirements shall continue in effect for the life of the property. In the event this
Agreement expires, or terminates, the requirements for this Section shall remain in effect for activities or
property funded with said funds, unless action is taken by the State government to relieve COUNTY of
these obligations
22.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services, because of race,
religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age or
gender, pursuant to all applicable State and Federal statutes and regulations.
23.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A.Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45 C.F.R. Part
80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance from
discriminating against persons based on race, color, national origin, sex, disability or religion. This is
interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive and quality bilingual
services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients, including, but not limited to, assessing the
cultural and linguistic needs of its clients, training of staff on the policies and procedures, and monitoring its
language assistance program. The CONTRACTOR’s procedures must include ensuring compliance of any
sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR’s services who have limited or no English language proficiency,
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including services to persons who are deaf or blind. Interpreter and translation services shall be provided
as necessary to allow such participants meaningful access to the programs, services and benefits provided
by CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR’s “vital
documents” (those documents that contain information that is critical for accessing CONTRACTOR’s
services or are required by law) shall be provided to participants at no cost to the participant.
CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or
translate for a program participant, or who directly communicate with a program participant in a language
other than English, demonstrate proficiency in the participant's language and can effectively communicate
any specialized terms and concepts peculiar to CONTRACTOR’s services.
E.In compliance with the State mandated Culturally and Linguistically Appropriate
standards as published by the Office of Minority Health, CONTRACTOR must submit to COUNTY for
approval, within sixty (60) days from date of contract execution, CONTRACTOR’s plan to address all
fifteen (15) national cultural competency standards as set forth in the “National Standards on Culturally and
Linguistically Appropriate Services (CLAS)”. COUNTY’s annual on-site review of CONTRACTOR shall
include collection of documentation to ensure all national standards are implemented. As the national
competency standards are updated, CONTRACTOR’s plan must be updated accordingly. Cultural
competency training for CONTRACTOR’s staff should be substantively integrated into health professions
education and training at all levels, both academic and functional, including core curriculum, professional
licensure, and continuing professional development programs. CONTRACTOR on a monthly basis shall
provide COUNTY DBH a monthly monitoring tool/report that shows all CONTRACTOR’s staff cultural
competency trainings completed.
24.AMERICANS WITH DISABILITIES ACT
CONTRACTOR 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 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
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11135 codifies section 508 of the Act requiring accessibility of electronic and information technology.
25.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon
written request to the Secretary of the United States Department of Health and Human Services, or upon
request to the Comptroller General of the United States General Accounting Office, or any of their duly
authorized representatives, a copy of this Agreement and such books, documents, and records as are
necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR under
this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any of its
duties under this Agreement through a subcontract, with a value or cost of Ten Thousand and No/100
Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such Agreement
shall contain a clause to the effect that until the expiration of four (4) years after the furnishing of such
services pursuant to such subcontract, the related organizations shall make available, upon written request
to the Secretary of the United States Department of Health and Human Services, or upon request to the
Comptroller General of the United States General Accounting Office, or any of their duly authorized
representatives, a copy of such subcontract and such books, documents, and records of such organization
as are necessary to verify the nature and extent of such costs.
26.SINGLE AUDIT CLAUSE
A.If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars ($750,000.00)
or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in
accordance with the requirements of the Single Audit Standards as set forth in Office of Management and
Budget (OMB) Circular A-133. CONTRACTOR shall submit said audit and management letter to
COUNTY. The audit must include a statement of findings or a statement that there were no findings. If
there were negative findings, CONTRACTOR must include a corrective action plan signed by an
authorized individual. CONTRACTOR agrees to take action to correct any material non-compliance or
weakness found as a result of such audit. Such audit shall be delivered to COUNTY’s DBH Business
Office, for review within nine (9) months of the end of any fiscal year in which funds were expended and/or
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received for the program. Failure to perform the requisite audit functions as required by this Agreement
may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option, contracting with a
public accountant to perform said audit, or, may result in the inability of COUNTY to enter into future
agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR’s Federal contracts do not
exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR’s only
funding is through Drug related Medi-Cal. If a single audit is not applicable, a program audit must be
performed and a program audit report with management letter shall be submitted by CONTRACTOR to
COUNTY as a minimum requirement to attest to CONTRACTOR’s solvency. Said audit report shall be
delivered to COUNTY’s DBH Business Office, for review no later than nine (9) months after the close of
the fiscal year in which the funds supplied through this Agreement are expended. Failure to comply with
this Act may result in COUNTY performing the necessary audit tasks or contracting with a qualified
accountant to perform said audit. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or
weakness found as a result of such audit. Audit work performed by COUNTY under this paragraph shall
be billed to the CONTRACTOR at COUNTY cost, as determined by COUNTY’s Auditor-
Controller/Treasurer-Tax Collector.
C.CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal
Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
least three (3) years following final payment under this Agreement or the closure of all other pending
matters, whichever is later.
27.COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached hereto and
incorporated herein by reference and made part of this Agreement. Within thirty (30) days of entering into
this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR’s employees, agents
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and subcontractors providing services under this Agreement certify in writing, that he or she has received,
read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall
ensure that within thirty (30) days of hire, all new employees, agents and subcontractors providing services
under this Agreement shall certify in writing that he or she has received, read, understood, and shall abide
by the Contractor Code of Conduct and Ethics. CONTRACTOR understands that the promotion of and
adherence to the Code of Conduct is an element in evaluating the performance of CONTRACTOR and its
employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete documentation
and billing or billing/reimbursement training. All new employees, agents and subcontractors shall attend
the appropriate training within 30 days of hire. Each individual who is required to attend training shall
certify in writing that he or she has received the required training. The certification shall specify the type of
training received and the date received. The certification shall be provided to the COUNTY’s Compliance
Officer at 3133 N. Millbrook, Fresno, California 93703. CONTRACTOR agrees to reimburse COUNTY for
the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result of
CONTRACTOR’s violation of the terms of this Agreement.
28.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither it, nor any of its
officers, are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs; that neither it, nor any of its officers, have been convicted of a criminal offense
related to the provision of health care items or services; nor has it, or any of its officers, been reinstated to
participate in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or
ineligibility. If COUNTY learns, subsequent to entering into a contract, that CONTRACTOR is ineligible on
these grounds, COUNTY will remove CONTRACTOR from responsibility for, or involvement with,
COUNTY’s business operations related to the Federal Health Care Programs and shall remove such
CONTRACTOR from any position in which CONTRACTOR’s compensation, or the items or services
rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by
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Federal Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR
is reinstated into participation in the Federal Health Care Programs.
A.If COUNTY has notice that either CONTRACTOR, or its officers, has been charged
with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during the
term of any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the
accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of the
charges or the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services under
this Agreement, will be queried as to whether (1) they are now or ever have been excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they have been
convicted of a criminal offense related to the provision of health care items or services; and or (3) they
have been reinstated to participate in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility.
1)In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
2)Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
C.CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected to
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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 participate in the Federal Health Care Program after a period of exclusion, suspension, debarment, or
ineligibility. In the event any existing employee or subcontractor informs CONTRACTOR that he or she is
excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs,
or has been convicted of a criminal offense relating to the provision of health care services,
CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
relating to services provided to COUNTY.
1)CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is
providing professional services under this Agreement is excluded, suspended, debarred or otherwise
ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
to the provision of health care services.
2)Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement, or require adequate assurance (as defined by
COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
to protect the interests of COUNTY consumers.
D.CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating to
CONTRACTOR’s compliance with the provisions of this Section.
E.CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation of
CONTRACTOR’s obligations as described in this Section.
29.PUBLICITY PROHIBITION
None of the funds, materials, property or services provided directly or indirectly under this
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Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e., purchasing of
tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the above,
publicity of the services described in Section One (1) of this Agreement shall be allowed as necessary to
raise public awareness about the availability of such specific services when approved in advance by
COUNTY’s DBH Director or designee and at a cost to be provided in Exhibit B for such items as
written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related
expense(s).
30.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client or a
client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (l 0th) day of the following month,
in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and attach
documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of their
right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to
State licensing bodies that affect COUNTY clients within twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY clients,
CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
the complaint, the complaint and CONTRACTOR's disposition of, or corrective action taken to resolve the
complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit G.
CONTRACTOR shall file an incident report for all incidents involving clients, following the protocol and
using the worksheet identified in Exhibit F and incorporated herein by reference and made part of this
Agreement.
31.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104, and
455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR by completing Exhibit H, “Disclosure of
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Ownership and Control Interest Statement”, attached hereto and by this reference incorporated herein and
made part of this Agreement. CONTRACTOR shall submit this form to the COUNTY’s DBH within thirty
(30)days of the effective date of this Agreement. Additionally, CONTRACTOR shall report any changes to
this information within thirty-five (35) days of occurrence by completing Exhibit H, “Disclosure of Ownership
and Control Interest Statement.” Submissions shall be scanned pdf copies and are to be sent via email to
DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
32.DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them, their
owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR”):
A.Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1)Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction;
2)Violation of a federal or state antitrust statute;
3)Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
or
4)False statements or receipt of stolen property.
B.Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR from
further business consideration. The information will be considered as part of the determination of whether
to continue and/or renew this Agreement and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that the CONTRACTOR failed to disclose required information, any contract awarded to such
CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms
and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
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Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit I, attached hereto
and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
must immediately advise the COUNTY’s DBH in writing if, during the term of this Agreement: (1)
CONTRACTOR becomes suspended, debarred, excluded or ineligible for participation in federal or state
funded programs or from receiving federal funds as listed in the excluded parties’ list system
(http://www.epls.gov); or (2) any of the above listed conditions become applicable to CONTRACTOR.
CONTRACTOR shall indemnify, defend and hold the COUNTY harmless for any loss or damage resulting
from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification
Regarding Debarment, Suspension, and Other Responsibility Matters.
33.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR changes its
status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services under
this Agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR is a party
and in which one or more of its directors has a material financial interest. Members of the Board of
Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a
Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit J and incorporated herein by
reference and made part of this Agreement, and submitting it to the COUNTY prior to commencing with
the self-dealing transaction or immediately thereafter.
34.AUDITS AND INSPECTIONS
The CONTRACTOR shall with 24 hours advance notice, and as often as the COUNTY may
deem necessary, make available to the COUNTY for examination all of its records and data with respect to
the matters covered by this Agreement. The CONTRACTOR shall, upon request by the COUNTY, permit
the COUNTY to audit and inspect all such records and data necessary to ensure CONTRACTOR’s
compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
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CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period of
three (3) years after final payment under contract (California Government Code section 8546.7).
35.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County Chief Executive Officer Department of Behavioral Health RH Community Builders 1925 E. Dakota Ave 352 Bedford Ave Fresno, CA 93726 Fresno, CA 93711
All notices between the COUNTY and CONTRACTOR 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 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
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 claims 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).
36.GOVERNING LAW
Venue for any action arising out of or related to the Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
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Agreement shall be governed in all respects by the laws of the State of California.
37.ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written.
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Wayne Rutledge , Chief Executive Officer
Print Name & Title
352 W Bedford #110
Fresno CA 93711
Mailing Address
18 FOR ACCOUNTING USE ONLY :
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Fund/Subclass: 0001/10000
Org No.: 5630
Account No .: 7295
COUNTY OF FRESNO
Ernest Buddy Mendes,
Chairman of the Board of Supervisors
of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno , State of California
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Exhibit A
Page 1 of 6
SHORT-TERM LODGING DRIVEN BY PEER SUPPORT SERVICES
SCOPE OF WORK
ORGANIZATION: RH Community Builders
ADDRESS: 352 Bedford Ave. Suite 110, Fresno, CA. 93711
SERVICE ADDRESS: 1040 N. Pleasant Ave. Fresno, CA. 93728
INTRODUCTION
RH Community Builders (RHCB) will provide short-term lodging services to individuals with
severe mental illness who are experiencing or at risk of homelessness. The intent of these
services is to gain insight through a pilot research project on what can enhance and increase
engagement of individuals who are homeless or at risk for homelessness, with the onset of an
early or severe mental illness and who are not engaging in care due to being in the
precontemplation stage of change.
TARGET POPULATION
The target population shall be adults 18 years and older living with a Severe Mental Illness
(SMI) and/or Co-Occuring Disorder (mental health and substance use disorder) who are in the
precontemplation stage of change to engage in the behavioral health system and also
experiencing homelessness or are at risk of becoming homeless. The program will not be open
to referrals from organizations serving Fresno County’s much larger homeless population, nor is
this program geared towards families. Rather, the target population would be persons who
meet all of the following specific criteria:
1.Have an SMI
2.Homeless or at-risk of homelessness
3.Not engaged in behavioral health outpatient services (may have accessed care through the
emergency department, hospitals and/or jails)
4.Eligible for Fresno County Department of Behavioral Health (DBH) services
PROJECT DESCRIPTION
The Lodge will provide high quality, individualized services that aim to help clients identify what
their needs are, seek support, and grow in their desire for change. The program will integrate
Trauma Informed principles including empowering clients, providing peer support, and creating
a safe environment. With a dignity first approach, individuals will provide a significant voice in
their treatment planning and will feel empowered to voice their preference for services.
The program will provide short-term lodging driven by peer support services for 30 beds.
Services will be provided to individuals that are referred through a Fresno County approved
referral source such as the Emergency Room, Crisis Intervention Team, or Psychiatric Hospital.
Exhibit A
Page 2 of 6
All individuals will be immediately enrolled in The Lodge and within 72 hours and a Peer
Support Specialist will engage the individual to do an additional assessment to gain a better
understanding of the individual’s needs and barriers.
Intake to The Lodge will be brief and only gather basic information to allow individuals to settle
in before additional assessments are conducted. The Peer Support Specialist will begin building
rapport with the individual and encourage the individual to begin attending supports that are
most appropriate for their needs. Peer support staff to be trained to use motivational
interviewing as a primary engagement tool.
Individuals will be rapidly accepted into The Lodge after a brief screening to ensure they meet
criteria for the program. The Lodge will operate under low-barrier standards, meaning referred
individual’s may still be active in addiction, but will not be permitted to bring illegal drugs or
alcohol into the facility.
Staff will be trained to search individual’s belongings upon entry and allow individuals to
surrender any drugs, alcohol, or weapons without penalty. Individual’s will be permitted to bring
their personal belongings into the facility and RHCB will provide a secure location for other
belongings such as camping gear, trailers, or excessive belongings.
At the time of arrival, individuals and the staff will complete an inventory form of which a copy
will be provided to the individual and placed in the individual’s file. Individuals will not be
penalized for surrendering illegal drugs or weapons, but such items will not be returned. Illegal
drugs, weapons, and alcohol will be logged into a destruction log and immediately disposed of
properly by a member of the Management Team.
Once a individual’s belongings have been searched, staff will assist the individual with getting
settled into their bed. All bedroom areas will have access to showers. Individuals will have
access to no cost laundry facilities and offered hygiene supplies and clothing if needed. RHCB
understands that individuals may enter The Lodge immediately after crisis and may need time to
rest and become comfortable. Individuals will not be pressured to immediately engage if they
are not ready and individuals will drive the pace of their treatment throughout their stay at The
Lodge.
The Lodge will be well equipped with all needed supplies including hygiene product, clothes,
and other basic necessities to ensure that individuals feel their physiological needs are met. The
Lodge will offer three full meals per day with snacks available between meals.
RHCB will operate The Lodge with a Housing First model based on the philosophy that safe and
stable housing will be the entry point to services, not the reward for entry into services. RHCB
fully embraces the principles of Housing First including harm reduction where individuals do not
have to be clean and sober to enter housing and individuals are not required to participate in
scheduled services such as groups or individual meetings during their stay.
RHCB will seek to remove as many barriers as possible to make it possible for individuals to
receive services. The Lodge will accept referred individuals to “come as you are”, including with
their pets and belongings. RHCB will work with individuals to keep their pets with them while in
services and provide kennels for pets along with ample storage space for individuals to secure
their belongings.
Exhibit A
Page 3 of 6
Sobriety will not be a condition of entry into The Lodge and staff will be trained to recognize
when an individual is under the influence or going through withdrawal. The Licensed Vocational
Nurse (LVN) will be available to monitor an individual who is going through detoxification from
substance use. All staff will be trained on emergency protocols and when emergency medical
personal should be contacted. Narcan will be available as needed and all staff will be trained in
administering Narcan as well as the safety protocols to follow after administration. Narcan will
be stored and secured in the Medication Cabinet and also in common areas to allow easy
access. Individuals will be encouraged to participate in recovery services such as Narcotics
Anonymous (NA) and Alcoholics Anonymous (AA) if substance use disorder treatment is a
needed. Clients will also be linked to residential or outpatient substance use disorder treatment
through Fresno County if they express a desire for treatment. The Peer Support Specialists and
Case Managers will be fully trained on how to access treatment services and be available to
support individuals in accessing services. RHCB will provide transportation to and from
treatment if services become an active piece of the individual’s treatment plan.
The length of stay is 45 days. The anticipated average individual length of stay in the Lodge
shall be in accordance with each individual’s assessed needs, but not exceed 45 days.
The Lodge will aim to not only link, but fully engage, individuals into additional services.
Individuals will become engaged into the Coordinated Entry System (CES) to ensure individuals
become eligible for housing programs. Individuals will be considered successfully discharged
when they have been accepted and engaged by an ongoing service provider.
STAFFING
Staff providing direct services to individuals includes the following:
•Peer Support Specialists
•A Licensed Vocational Nurse
•Case Managers
•Clinicians
RHCB will also support the program with interns who are currently pursuing degrees in Alcohol
and Drug Counseling and Social Work in order to provide additional resources to the individuals
served.
The Lodge will also be supported by a Kitchen Manager, Driver, and Janitor. The Lodge will be
staffed 24/7 by Peer Support Specialists and will have bilingual staff available 24/7. All staff will
also be trained on accessing the Language Line to provide translation services, if needed. At a
minimum, The Lodge will be staffed at a ratio of 1:10 for direct staff to individuals served and at
many times, there will be a ratio of 1:7.5 staff to individuals served.
REPORTING REQUIREMENTS AND OUTCOME MONITORING
Throughout the process of services, RHCB will provide regular updates to DBH summarizing
how the goals and objectives were met through the provision of services.
RHCB shall actively participate with DBH and any outside consultants for performance
monitoring and reporting requirements.
Exhibit A
Page 4 of 6
At minimum, one performance indicator will be identified for each of the four Commission on
Accreditation of Rehabilitation Facilities (CARF) domains listed below.
a.Access to care: The ability of individuals to receive the right service at the right time.
Examples include:
1.Timeliness of bridging prescriptions
2.Timeliness of identifying clients with a serious mental illness
3.Timeliness between individual referral for assessment and completion of assessment;
assessment to first treatment service; and, first treatment service to next follow-up
4.Timeliness of subsequent follow-up visits
5.Timeliness of response to sick call/health service requests
b.Effectiveness: Objective results achieved through health care services. Examples include:
1.Effectiveness of crisis interventions
2.Effectiveness of treatment interventions (medical and behavioral health indicators)
3.Effectiveness of discharge planning (such as percentage of clients successfully linked to
County programs, community providers, and/or other community resources after
release)
4.Timely continuity of verified community prescriptions for medication(s), upon individual’s
release
5.Effectiveness of transportation coordination, upon release
c.Efficiency: The demonstration of the relationship between results and the resources used to
achieve them.
Examples include:
1.Cost per individual served
2.Number of units of services per FTE by discipline
3.Number of individuals served per general population
4.Comparison of numbers served against industry standards
d.Satisfaction and Compliance: The degree to which individuals, County, and other
stakeholders are satisfied with the services.
Examples include:
1.Audits and other performance and utilization reviews of health care services and
compliance with agreement terms and conditions
2.Surveys of persons served, family members, other health care providers, and other
stakeholders
The following items listed below represent program goals to be achieved by RHCB.
Effectiveness:
Exhibit A
Page 5 of 6
1.85% of individuals will successfully engage in outpatient mental health or substance
abuse treatment.
2.The number of unique visits to the Crisis Stabilization Unit for each individual served will
be reduced by 75%.
3.The number of unique visits to the Emergency room will be reduced by 85% for each
individual served.
Efficiency:
1.RHCB will establish a baseline cost per individual served in the initial partial year.
2.RHCB will reduce cost per individual served annually thereafter.
Access:
1.Wait time from admission into the Lodge to initial peer assessment by RHCB will be 72
hours or less.
2.Once an individual has moved from the “pre-contemplative” stage and determined that
they are interested in seeking mental-health services, a mental-health assessment by
RHCB will be done within 48 hours.
Satisfaction:
1.85% of individuals served will report “Satisfied” or “Very Satisfied” with services on
RHCB’s individuals served exit survey.
2. 85% of the families of individuals served that are actively involved in the lives of
individuals served will rate “Significant” or “Critical” in response to Importance of The
Lodge in your loved one accessing ongoing services.
During the term of this Agreement, additional data collection opportunities may be identified and
implemented to support the Mental Health Services Act (MHSA) Innovation Component
research aspects of The Lodge program.
DBH and RHCB will review additional outcomes, MHSA requirements and CARF standards to
establish any further agreed upon outcomes to be tracked. RHCB will actively collaborate with a
third-party consultant to develop and refine data collection and reporting processes in order to
ensure compliance with MHSA Innovation Component requirements.
ADDITIONAL PERFORMANCE MONITORING REQUIREMENTS:
RHCB shall:
1)Be required to comply with any requirements as related to performance outcomes, quality of
life and/or customer satisfaction as a Medi-Cal Organizational Provider, as described in
Exhibit H.
2)Be required to comply with all State regulations regarding State Performance Outcomes
measurement requirements and participate in the outcomes measurement process as
required by DBH.
Exhibit A
Page 6 of 6
3)Participate in performance outcomes throughout each term of this Agreement. DBH will
notify RHCB when its participation is required. The performance outcome measurement
process will not be limited to survey instruments but will also include, as appropriate,
individual and staff interviews, chart reviews, and other methods of obtaining needed
information.
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.30 11,700$ -$ 11,700$
1102 Program Manager 1.00 25,740 - 25,740
1103 Clinical Supervisor 1.00 20,800 - 20,800
1104 Peer Supervisor 1.00 7,930 - 7,930
1105 Office Manager 1.00 8,320 - 8,320
1106 Peer Support Specalist I 3.00 7,930 - 7,930
1107 Peer Support Specalist II 4.00 11,786 - 11,786
1108 Clinician 2.00 20,375 - 20,375
1109 Licensed Vocational Nurse 1.00 6,500 - 6,500
1110 Case Manager 2.00 9,750 - 9,750
1111 Kitchen Manager 0.75 2,210 - 2,210
1112 Overnight Security Monitor 1.50 3,900 - 3,900
1113 Driver 0.75 1,105 - 1,105
1114 Janitor 0.50 2,551 - 2,551
1115 Bookkeeper 0.25 4,290 - 4,290
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 20.05 144,887$ -$ 144,887$
Employee Benefits
Acct #Admin Direct Total
1201 -$ -$ -$
1202 22,519 22,519
1203 28,639 28,639
1204 - - -
1205 - - -
1206 - - -
51,158$ -$ 51,158$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 20,214$ 20,214$
1302 24,942 24,942
1303 11,085 11,085
1304 - - -
1305 - - -
1306 - - -
56,241$ -$ 56,241$
252,286$ -$ 252,286$
Other (Specify)
Employee Benefits Subtotal:
Description
1000: SALARIES & BENEFITS
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
OASDI
FICA/MEDICARE
SUI
Other (Specify)
PROGRAM EXPENSES
Other (Specify)
Other (Specify)
EMPLOYEE SALARIES & BENEFITS TOTAL:
The Lodge
RH Community Builders
Ramp Up 10/20/2020-1/31/2021
Description
Payroll Taxes & Expenses Subtotal:
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
1 of 16
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 8,000
2004 3,500
2005 -
2006 -
2007 -
2008 -
2009 1,850
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
13,350$
3000: OPERATING EXPENSES
Acct #Amount
3001 3,425$
3002 100
3003 6,500
3004 -
3005 8,500
3006 850
3007 -
3008 -
3009 3,150
3010 -
3011 -
3012 -
22,525$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001
4002 54,000
4003 -
4004 5,000
4005 2,700
4006 17,775
4007 -
4008 -
4009 -
4010 -
79,475$
5000: SPECIAL EXPENSES
Staff Mileage
Subscriptions & Memberships
Clothing, Food, & Hygiene
Other (Specify)
Other (Specify)
Office, Household & Program Supplies
Utility Vouchers
Program Supplies - Medical
Medication Supports
Household Items for Clients
Employment Support
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Client Transportation & Support
Client Housing Support
Other (Specify)
Other (Specify)
Rent/Lease Vehicles
FACILITIES/EQUIPMENT TOTAL:
OPERATING EXPENSES TOTAL:
Line Item Description
DIRECT CLIENT CARE TOTAL
Other (Specify)
Other (Specify)
Advertising
Rent/Lease Building
Building Maintenance
Education Support
Other Vehicle Insurance
Security
Utilities
Rent/Lease Equipment
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Vehicle Maintenance
Staff Development & Training
Child Care
Line Item Description
Line Item Description
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
2 of 16
Acct #Amount
5001 10,000$
5002 -
5003 -
5004 -
5005 -
5006 -
5007 -
5008 -
10,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 27,000$
6002 8,200
6003 1,500
6004 -
6005 -
6006 630
6007 -
6008 8,000
6009 -
6010 -
6011 -
6012 -
45,330$
7000: FIXED ASSETS
Acct #Amount
7001 34,500$
7002 9,650
7003 28,000
7004 11,500
7005 7,200
7006 -
7007 -
7008 -
90,850$
Line Item Description
Consultant (Network & Data Management)
Contractual/Consulting Services (Specify)
Translation Services
External Audit
Insurance (Specify):
Other recuriting fees/staffing agency fees
Other Assets over $500 with Lifespan of 2 Years +
513,816$ TOTAL PROGRAM EXPENSES
FIXED ASSETS EXPENSES TOTAL
ADMINISTRATIVE EXPENSES TOTAL
SPECIAL EXPENSES TOTAL:
Line Item Description
Professional Liability Insurance
Accounting/Bookkeeping
Payroll Services
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Assets over $5,000/unit (Specify)
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other (Specify)
Other (Specify)
Administrative Overhead
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Line Item Description
HMIS (Health Management Information System)
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
3 of 16
Acct #Service Units Rate Amount
8001 Mental Health Services 0 - -$
8002 Case Management 0 - -
8003 Crisis Services 0 - -
8004 Medication Support 0 - -
8005 Collateral 0 - -
8006 Plan Development 0 - -
8007 Assessment 0 - -
8008 Rehabilitation 0 - -
0 -$
0%
-
0%-
-$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 513,816
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
513,816$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$
Grants (Specify)
Other (Specify)
Other (Specify)
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Federal Financial Participation (FFP) %
8200 - REALIGNMENT
NET PROGRAM COST:
PROGRAM FUNDING SOURCES
TOTAL PROGRAM FUNDING SOURCES:513,816$
-$
SUBSTANCE USE DISORDER FUNDS TOTAL
MEDI-CAL FFP TOTAL
MHSA TOTAL
Line Item Description
Line Item Description
8100 - SUBSTANCE USE DISORDER FUNDS
OTHER REVENUE TOTAL
Line Item Description
8400 - OTHER REVENUE
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
MHSA Program Name
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
Line Item Description
REALIGNMENT TOTAL
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
4 of 16
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.30 13,000$ -$ 13,000$
1102 Program Manager 1.00 18,000 10,599 28,599
1103 Clinical Supervisor 1.00 22,000 12,666 34,666
1104 Peer Supervisor 1.00 17,000 5,533 22,533
1105 Office Manager 1.00 16,466 - 16,466
1106 Peer Support Specalist I 3.00 - 39,649 39,649
1107 Peer Support Specalist II 4.00 - 58,932 58,932
1108 Clinician 2.00 - 45,933 45,933
1109 Licensed Vocational Nurse 1.00 - 21,667 21,667
1110 Case Manager 2.00 - 32,288 32,288
1111 Kitchen Manager 0.75 - 11,050 11,050
1112 Overnight Security Monitor 1.50 - 19,500 19,500
1113 Driver 0.75 - 11,050 11,050
1114 Janitor 0.50 - 6,933 6,933
1115 Bookkeeper 0.25 4,767 - 4,767
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 20.05 91,233$ 275,800$ 367,033$
Employee Benefits
Acct #Admin Direct Total
1201 875$ 2,084$ 2,959$
1202 5,879 19,143 25,022
1203 7,519 40,213 47,732
1204 - - -
1205 - - -
1206 - - -
14,273$ 61,440$ 75,713$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 5,283$ 17,178$ 22,461$
1302 10,429 21,196 31,625
1303 2,897 9,421 12,318
1304 - - -
1305 - - -
1306 - - -
18,609$ 47,795$ 66,404$
124,115$ 385,035$ 509,150$
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
FICA/MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
The Lodge
RH Community Builders
Fiscal Year (FY) 2/1/2021-6/30/2021
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Employee Benefits Subtotal:
Description
OASDI
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
5 of 16
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 11,000
2004 38,500
2005 -
2006 -
2007 -
2008 -
2009 3,000
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
52,500$
3000: OPERATING EXPENSES
Acct #Amount
3001 3,425$
3002 730
3003 11,500
3004 -
3005 2,500
3006 1,938
3007 -
3008 900
3009 3,500
3010 -
3011 -
3012 -
24,493$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 6,000$
4002 60,000
4003 1,750
4004 2,500
4005 3,000
4006 20,000
4007 -
4008 -
4009 -
4010 -
93,250$
5000: SPECIAL EXPENSES
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Other Vehicile Insurance
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Line Item Description
Child Care
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
6 of 16
Acct #Amount
5001 1,500$
5002 -
5003 -
5004 3,500
5005 -
5006 -
5007 -
5008 -
5,000$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 25,000$
6002 6,450
6003 1,500
6004 8,000
6005 -
6006 700
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
41,650$
7000: FIXED ASSETS
Acct #Amount
7001 2,000$
7002 1,500
7003 2,300
7004 -
7005 1,500
7006 -
7007 -
7008 -
7,300$ FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 733,343$
Assets over $5,000/unit (Specify)
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Services
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Insurance (Specify):
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
7 of 16
Acct #Service Units Rate Amount
8001 Mental Health Services 10,000 2.73 27,300$
8002 Case Management 10,000 2.11 21,100
8003 Crisis Services 500 4.11 2,055
8004 Medication Support 1,500 5.04 7,560
8005 Collateral 5,000 2.73 13,650
8006 Plan Development 3,000 2.73 8,190
8007 Assessment 5,000 2.73 13,650
8008 Rehabilitation 15,000 2.73 40,950
50,000 134,455$
68%
91,429
100%91,429
91,429$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment (0)$
(0)$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 641,914
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
641,914$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:733,343$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
8 of 16
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.30 31,200$ 31,200$
1102 Program Manager 1.00 55,000 13,600 68,600
1103 Clinical Supervisor 1.00 60,000 23,200 83,200
1104 Peer Supervisor 1.00 40,000 14,080 54,080
1105 Office Manager 1.00 39,519 39,519
1106 Peer Support Specalist I 3.00 95,142 95,142
1107 Peer Support Specalist II 4.00 141,413 141,413
1108 Clinician 2.00 110,240 110,240
1109 Licensed Vocational Nurse 1.00 52,000 52,000
1110 Case Manager 2.00 78,446 78,446
1111 Kitchen Manager 0.75 26,520 26,520
1112 Overnight Security Monitor 1.50 46,800 46,800
1113 Driver 0.75 26,520 26,520
1114 Janitor 0.50 16,640 16,640
1115 Bookkeeping 0.25 11,440 11,440
1116 -
1117 -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 20.05 237,159$ 644,601$ 881,760$
Employee Benefits
Acct #Admin Direct Total
1201 2,600$ 5,002$ 7,602$
1202 14,250 45,943 60,193
1203 18,795 96,512 115,307
1204 - - -
1205 - - -
1206 - - -
35,645$ 147,457$ 183,102$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 12,985$ 41,227$ 54,212$
1302 15,867 50,869 66,736
1303 7,023 22,609 29,632
1304 - - -
1305 - - -
1306 - - -
35,875$ 114,705.00$ 150,580.00$
308,679$ 906,763$ 1,215,442$
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
FICA/MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
The Lodge
RH Community Builders
Fiscal Year (FY) 2021-2022
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Employee Benefits Subtotal:
Description
OASDI
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
9 of 16
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 22,504
2004 78,225
2005 -
2006 -
2007 -
2008 -
2009 7,150
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
107,879$
3000: OPERATING EXPENSES
Acct #Amount
3001 8,220$
3002 1,750
3003 27,600
3004 -
3005 3,900
3006 4,650
3007 -
3008 1,200
3009 8,400
3010 -
3011 -
3012 -
55,720$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 8,500$
4002 144,000
4003 4,200
4004 6,000
4005 3,600
4006 47,400
4007 -
4008 -
4009 -
4010 -
213,700$
5000: SPECIAL EXPENSES
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Other Vehicle Insurnace
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Line Item Description
Child Care
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
10 of 16
Acct #Amount
5001 3,600$
5002 -
5003 -
5004 6,000
5005 -
5006 -
5007 -
5008 -
9,600$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 53,697$
6002 24,500
6003 2,500
6004 12,000
6005 -
6006 1,672
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
94,369$
7000: FIXED ASSETS
Acct #Amount
7001 3,534$
7002 1,500
7003 1,088
7004 -
7005 -
7006 -
7007 -
7008 -
6,122$ FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 1,702,832$
Assets over $5,000/unit (Specify)
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Services
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Insurance (Specify):
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
11 of 16
Acct #Service Units Rate Amount
8001 Mental Health Services 32,400 2.73 88,452$
8002 Case Management 32,400 2.11 68,364
8003 Crisis Services 3,600 4.11 14,796
8004 Medication Support 7,200 5.04 36,288
8005 Collateral 16,200 2.73 44,226
8006 Plan Development 10,800 2.73 29,484
8007 Assessment 16,200 2.73 44,226
8008 Rehabilitation 74,000 2.73 202,020
192,800 527,856$
70%
369,499
100%369,499
369,499$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment (0)$
(0)$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 1,333,333
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
1,333,333$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:1,702,832$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
12 of 16
Employee Salaries
Acct #Position FTE Admin Direct Total
1101 Executive Director 0.30 31,200$ -$ 31,200$
1102 Program Manager 1.00 55,000 17,200 72,200
1103 Clinical Supervisor 1.00 56,000 27,200 83,200
1104 Peer Supervisor 1.00 42,000 17,677 59,677
1105 Office Manager 1.00 39,519 - 39,519
1106 Peer Support Specalist I 3.00 - 99,838 99,838
1107 Peer Support Specalist II 4.00 - 143,228 143,228
1108 Clinician 2.00 - 116,478 116,478
1109 Licensed Vocational Nurse 1.00 - 54,079 54,079
1110 Case Manager 2.00 - 76,880 76,880
1111 Kitchen Manager 0.75 - 29,634 29,634
1112 Overnight Security Monitor 1.50 - 48,800 48,800
1113 Driver 0.75 - 27,000 27,000
1114 Janitor 0.50 - 17,677 17,677
1115 Bookkeeper 0.25 11,960 - 11,960
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 20.05 235,679$ 675,691$ 911,370$
Employee Benefits
Acct #Admin Direct Total
1201 2,500$ 5,002$ 7,502$
1202 14,800 47,398 62,198
1203 18,795 96,512 115,307
1204 - - -
1205 - - -
1206 - - -
36,095$ 148,912$ 185,007$
Payroll Taxes & Expenses:
Acct #Admin Direct Total
1301 12,678$ 41,228$ 53,906$
1302 15,643 50,869 66,512
1303 6,952 22,609 29,561
1304 - - -
1305 - -
1306 - -
35,273$ 114,706$ 149,979$
307,047$ 939,309$ 1,246,356$
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Taxes & Expenses Subtotal:
EMPLOYEE SALARIES & BENEFITS TOTAL:
FICA/MEDICARE
SUI
Retirement
Worker's Compensation
Health Insurance
Other (Specify)
Other (Specify)
Other (Specify)
The Lodge
RH ommunity Builders
Fiscal Year (FY) 2022-2023
PROGRAM EXPENSES
1000: SALARIES & BENEFITS
Description
Employee Benefits Subtotal:
Description
OASDI
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
13 of 16
2000: CLIENT SUPPORT
Acct #Amount
2001 -$
2002 -
2003 21,580
2004 78,225
2005 -
2006 -
2007 -
2008 -
2009 7,400
2010 -
2011 -
2012 -
2013 -
2014 -
2015 -
2016 -
107,205$
3000: OPERATING EXPENSES
Acct #Amount
3001 8,500$
3002 2,000
3003 26,500
3004 -
3005 3,900
3006 4,860
3007 -
3008 1,200
3009 8,400
3010 -
3011 -
3012 -
55,360$
4000: FACILITIES & EQUIPMENT
Acct #Amount
4001 9,024$
4002 144,000
4003 4,200
4004 6,000
4005 3,600
4006 47,400
4007 -
4008 -
4009 -
4010 -
214,224$
5000: SPECIAL EXPENSES
FACILITIES/EQUIPMENT TOTAL:
Security
Utilities
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
OPERATING EXPENSES TOTAL:
Line Item Description
Building Maintenance
Rent/Lease Building
Rent/Lease Equipment
Rent/Lease Vehicles
Subscriptions & Memberships
Vehicle Maintenance
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Telecommunications
Printing/Postage
Office, Household & Program Supplies
Advertising
Staff Development & Training
Staff Mileage
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
DIRECT CLIENT CARE TOTAL
Line Item Description
Household Items for Clients
Medication Supports
Program Supplies - Medical
Utility Vouchers
Other (Specify)
Other (Specify)
Client Housing Support
Client Transportation & Support
Clothing, Food, & Hygiene
Education Support
Employment Support
Line Item Description
Child Care
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
14 of 16
Acct #Amount
5001 2,077$
5002 -
5003 -
5004 4,500
5005 -
5006 -
5007 -
5008 -
6,577$
6000: ADMINISTRATIVE EXPENSES
Acct #Amount
6001 53,881$
6002 24,500
6003 2,500
6004 12,000
6005 -
6006 1,673
6007 -
6008 -
6009 -
6010 -
6011 -
6012 -
94,554$
7000: FIXED ASSETS
Acct #Amount
7001 2,449$
7002 1,500
7003 1,000
7004 -
7005 -
7006 -
7007 -
7008 -
4,949$ FIXED ASSETS EXPENSES TOTAL
TOTAL PROGRAM EXPENSES 1,729,225$
Assets over $5,000/unit (Specify)
Other (Specify)
Other (Specify)
Administrative Overhead
Professional Liability Insurance
Accounting/Bookkeeping
External Audit
Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
SPECIAL EXPENSES TOTAL:
Line Item Description
Line Item Description
Computer Equipment & Software
Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data
Furniture & Fixtures
Leasehold/Tenant/Building Improvements
Other Assets over $500 with Lifespan of 2 Years +
ADMINISTRATIVE EXPENSES TOTAL
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Payroll Services
Other (Specify)
Other (Specify)
Other (Specify)
Other (Specify)
Insurance (Specify):
Line Item Description
Consultant (Network & Data Management)
HMIS (Health Management Information System)
Contractual/Consulting Services (Specify)
Translation Services
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
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Acct #Service Units Rate Amount
8001 Mental Health Services 32,400 2.73 88,452$
8002 Case Management 32,400 2.11 68,364
8003 Crisis Services 3,600 4.11 14,796
8004 Medication Support 7,200 5.04 36,288
8005 Collateral 16,200 2.73 44,226
8006 Plan Development 10,800 2.73 29,484
8007 Assessment 16,200 2.73 44,226
8008 Rehabilitation 74,000 2.73 202,020
192,800 527,856$
75%
395,892
100%395,892
395,892$
Acct #Amount
8101 Drug Medi-Cal -$
8102 SABG -$
-$
Acct #Amount
8201 Realignment -$
-$
Acct #MHSA Component Amount
8301 CSS - Community Services & Supports -$
8302 PEI - Prevention & Early Intervention -
8303 INN - Innovations 1,333,333
8304 WET - Workforce Education & Training -
8305 CFTN - Capital Facilities & Technology -
1,333,333$
Acct #Amount
8401 Client Fees -$
8402 Client Insurance -
8403 -
8404 -
8405 -
-$ OTHER REVENUE TOTAL
TOTAL PROGRAM FUNDING SOURCES:1,729,225$
NET PROGRAM COST: -$
MHSA TOTAL
8400 - OTHER REVENUE
Line Item Description
Grants (Specify)
Other (Specify)
Other (Specify)
PROGRAM FUNDING SOURCES
8000 - SHORT/DOYLE MEDI-CAL (FEDERAL FINANCIAL PARTICIPATION)
Line Item Description
Estimated Specialty Mental Health Services Billing Totals:
Estimated % of Clients who are Medi-Cal Beneficiaries
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries
Line Item Description
REALIGNMENT TOTAL
8300 - MENTAL HEALTH SERVICE ACT (MHSA)
MHSA Program Name
The Lodge
Federal Financial Participation (FFP) %
MEDI-CAL FFP TOTAL
8100 - SUBSTANCE USE DISORDER FUNDS
Line Item Description
SUBSTANCE USE DISORDER FUNDS TOTAL
8200 - REALIGNMENT
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit B
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Exhibit C
Page 1 of 2
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1.Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2.Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3.Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4.NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5.Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6.Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7.Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit C
Page 2 of 2
8.Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9.Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11.Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit D
Page 1 of 1
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 2
STATE MENTAL HEALTH REQUIREMENTS
1.CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2.PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3.CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4.NON-DISCRIMINATION
A.Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B.Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit E
Page 2 of 2
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C.Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D.Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5.PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights
Exhibit F
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
GGRRIIEEVVAANNCCEESS AANNDD IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
•The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
•When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
•Incident Report should be sent to:
DBH Program Supervisor
Exhibit F
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1.Background information of the incident:
2.Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3.Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4.Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit G
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
•How to access specialty mental health services
•How to file a grievance about services
•How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit G
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process – the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider’s claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit H
Page 1 of 2
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 H
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 I
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1.By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2.The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3.The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4.The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5.The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6.Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit I
2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a)Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b)Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c)(d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit J
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 J
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: