HomeMy WebLinkAbout32568Agreement No. 16-221
1 AGREEMENT
2 This Agreement is made and entered into this 24th day of _~M=a'-l-y __ , 2016, by and
3 between the C OUNTY O F FRESNO, a Political Subdivision ofthe State of California, hereinafter
4 referred to as "C O UNTY", and EXODUS RECOVERY, INC., a for-profit California corporation ,
5 whose address is 9808 Venice Blvd, Suite 700 , Culver City, CA 90232, hereinafter referred to as
6 "CONTRACTOR".
7 W I T N E S S E T H:
8 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a
9 qualified agency to operate an Adult Crisis Stabilization Center (Adult CSC) to provide crisis
10 stabilization services to adult clients, age 18 and older, who may be admitted on a voluntary or
11 involuntary basis regardless of the source of payment who are referred by DBH, a contract provider
12 with DBH, law enforcement, hospital emergency rooms , and Emergency Medical Services transports ;
13 and
14 WHEREAS, COUNTY, through DBH, is also in need of a qualified agency to operate a Youth
15 Crisis Stabilization Center (Youth CSC) to provide crisis stabilization services to children and youth
16 clients up to age 18 who may be admitted on a voluntary or involuntary basis regardless ofthe source
17 of payment, who are referred by the same agencies mentioned hereinabove ; and
18 WHEREAS , COUNTY, through DBH is also in need of a qualified agency to operate State-
19 mandated toll-free answering service (Access Line) in accordance with state and federal regulations,
2 0 California Code of Regulations (CCR): Title 9, Chapter 11 , Section 181 0.405(d)(f), California Code of
21 Regulations (CCR): Title 9 , Section 1850.205 , Code of Federal Regulations (CFR): Title 42 , Part 438 ,
2 2 Subpart F, and State Department of Health Care Services Program Oversight and Compliance -
2 3 Annual Protocol Review for Consolidation Specialty Mental Health Services and Other Funded
2 4 Services Section A -Access; and
2 5 WHEREAS, COUNTY, through its DBH , is a Mental Health Plan (MHP) as defined in Title 9
26 ofthe California Code of Regulations (CCR), Section 1810.226; and
2 7 WHEREAS , CONTRACTOR is qualified and willing to operate said Adult CSC, Youth CSC ,
2 8 and Access Line pursuant to the terms and conditions of this Agreement.
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Fres n o, CA
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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-1, “Adult Crisis Stabilization Center Scope of Work,” Exhibit A-2, “Youth Crisis
Stabilization Center Scope of Work,” and Exhibit A-3, “Access Line Scope of Work,” all 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. 952-5405 dated December 10, 2015, and
Addendum No. One (1) to COUNTY’s RFP No. 952-5405 dated January 4, 2016, herein collectively
referred to as COUNTY’s Revised RFP, and CONTRACTOR’s response to said Revised RFP dated
January 26, 2015, all incorporated herein by reference and made part of this Agreement. In the event
of any inconsistency among these documents, the inconsistency shall be resolved by giving
precedence in the following order of priority: 1) to this Agreement, including all Exhibits; 2) to the
Revised RFP, and 3) to the CONTRACTOR’s Response to the Revised RFP. A copy of COUNTY’s
Revised RFP No. 952-5405 and CONTRACTOR’s response thereto shall be retained and made
available during the term of this Agreement by COUNTY’s DBH Contracts Division.
C. It is acknowledged by all parties hereto that COUNTY’s DBH Contracts
Division unit shall monitor the Adult CSC, Youth CSC, and Access Line operated by
CONTRACTOR, in accordance with Section Fourteen (14) of this Agreement.
D. CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
consisting of staff from COUNTY’s DBH to discuss CSC requirements, Access Line requirements,
data reporting, training, policies and procedures, overall program operations and any problems or
foreseeable problems that may arise.
E. CONTRACTOR shall attend monthly County DBH meetings for mental health
providers as required by the COUNTY. Schedule for these meetings may change based on the needs
of the COUNTY.
F. CONTRACTOR shall maintain requirements as an MHP organizational provider
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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.
G. CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, CONTRACTOR shall have staff hired and in place for program services
and operations or COUNTY may, in addition to other remedies it may have, suspend referrals or
terminate this Agreement, in accordance with Section Three (3) of this Agreement.
H. CONTRACTOR’s affiliate EXODUS FOUNDATION, INC., a non-profit
Internal Revenue Code section 501(c)(3) corporation, shall execute a mutually agreeable lease
agreement with COUNTY for the lease of COUNTY-owned property located at 4411 E. Kings
Canyon Ave., Fresno, California 93702 (Building 319) as the site for CONTRACTOR’s provision of
Adult CSC, Youth CSC, and Access Line services under this Agreement. If CONTRACTOR or
CONTRACTOR’s affiliate fails to accomplish these tasks prior to providing services under this
Agreement, COUNTY may, in addition to other remedies it may have, suspend referrals or terminate
this Agreement, in accordance with Section Three (3) of this Agreement.
I. It is acknowledged by all parties hereto that COUNTY’s DBH shall be
responsible for COUNTY DBH approved facility improvements to the CSC. Payments for COUNTY
DBH approved improvements to the CSC will be funded by the COUNTY’S DBH. Said
improvements to the CSC shall be at the discretion of the COUNTY’s DBH Director or designee.
Improvements stated herein shall mean those improvements to the CSC designed to assist with the
operation of the CSC. The parties agree that the anticipated start date for the CONTRACTOR’s CSC
to commence serving clients will be July 1, 2016.
J. It is acknowledged by all parties hereto that landscaping, building maintenance,
and utilities for the CSC will be provided by COUNTY and COUNTY will invoice CONTRACTOR
for said services as further described in Section Five (5) of this Agreement.
2. TERM
The term of this Agreement shall be for a period of three (3) years, commencing July 1,
2016 through June 30, 2019. This Agreement may be extended for two (2) additional consecutive
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twelve (12) month periods upon written approval of both parties no later than thirty (30) days prior to
the first day of the next twelve (12) month extension period. The DBH Director or designee is
authorized to execute such written approval on behalf of COUNTY based on CONTRACTOR’S
satisfactory performance.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving the CONTRACTOR thirty (30) days advance written notice.
B. Breach of Contract - The COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of the 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 the COUNTY;
4) Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
any breach of this Agreement or any default which may then exist on the part of CONTRACTOR.
Neither shall such payment impair or prejudice any remedy available to the COUNTY with respect to
the breach or default. COUNTY shall have the right to demand of the CONTRACTOR the repayment
to the COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the
judgment of the COUNTY were not expended in accordance with the terms of this Agreement. The
CONTRACTOR shall promptly refund any such funds upon demand or, at the COUNTY’s option,
such repayment shall be deducted from future payments owing to CONTRACTOR under this
Agreement.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY upon the giving of sixty (60) days advance written notice
of an intention to terminate to CONTRACTOR.
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4. COMPENSATION
A. Maximum Compensation
(1) ADULT CSC:
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to
receive compensation based on actual cost for adult crisis stabilization services at the Adult CSC in
accordance with Exhibit B-1, “Adult Crisis Stabilization Center Budget,” attached hereto and by this
reference incorporated herein.
The maximum amount under this Agreement for the period July 1, 2016
through June 30, 2017 shall not exceed Six Million Five Hundred Twenty-Seven Thousand Seven
Hundred Sixty-Five and No/100 Dollars ($6,527,765.00).
For the period July 1, 2016 through June 30, 2017, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two Million Five
Hundred Forty-Five Thousand Eight Hundred Twenty-Eight and No/100 Dollars ($2,545,828.00) in
Medi-Cal Federal Financial Participation (FFP); Two Million Five Hundred Forty-Five Thousand
Eight Hundred Twenty-Eight and No/100 Dollars ($2,545,828.00) in Behavioral Health Realignment;
and One Million Four Hundred Thirty-Six Thousand One Hundred Eight and No/100 Dollars
($1,436,108.00) in other revenue sources to offset CONTRACTOR’s program costs, as set forth in
Exhibit B-1.
The maximum amount for the period July 1, 2017 through June 30, 2018
shall not exceed Six Million Seven Hundred Twenty-Three Thousand Six Hundred Twenty-Three and
No/Dollars ($6,723,623.00).
For the period July 1, 2017 through June 30, 2018, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two Million Six Hundred
Twenty-Two Thousand Two Hundred Thirteen and No/100 Dollars ($2,622,213.00) in Medi-Cal
Federal Financial Participation (FFP); Two Million Six Hundred Twenty-Two Thousand Two
Hundred Thirteen and No/100 Dollars ($2,622,213.00) in Behavioral Health Realignment; and One
Million Four Hundred Seventy-Nine Thousand One Hundred Ninety-Seven and No/100 Dollars
($1,479,197.00) in other revenue sources to offset CONTRACTOR’s program costs, as set forth in
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Exhibit B-1.
The maximum amount for the period July 1, 2018 through June 30, 2019
shall not exceed Six Million Nine Hundred Twenty-Five Thousand Three Hundred Thirty-Two and
No/100 Dollars ($6,925,332.00).
For the period July 1, 2018 through June 30, 2019, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two Million Seven
Hundred Thousand Eight Hundred Seventy-Nine and No/100 Dollars ($2,700,879.00) in Medi-Cal
Federal Financial Participation (FFP); Two Million Seven Hundred Thousand Eight Hundred Seventy-
Nine and No/100 Dollars ($2,700,879.00) in Behavioral Health Realignment; and One Million Five
Hundred Twenty-Three Thousand Five Hundred Seventy-Four and No/100 Dollars ($1,523,574.00)
in other revenue sources to offset CONTRACTOR’s program costs, as set forth in Exhibit B-1.
The maximum amount for the period July 1, 2019 through June 30, 2020
shall not exceed Seven Million One Hundred Thirty-Three Thousand Ninety-Two and No/100 Dollars
($7,133,092.00).
For the period July 1, 2019 through June 30, 2020, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two Million Seven
Hundred Eighty-One Thousand Nine Hundred Six and No/100 Dollars ($2,781,906.00) in Medi-Cal
Federal Financial Participation (FFP); Two Million Seven Hundred Eighty-One Thousand Nine
Hundred Six and No/100 Dollars ($2,781,906.00) in Behavioral Health Realignment; and One Million
Five Hundred Sixty-Nine Thousand Two Hundred Eighty and No/100 Dollars ($1,569,280.00) in
other revenue sources to offset CONTRACTOR’s program costs, as set forth in Exhibit B-1.
The maximum amount for the period July 1, 2020 through June 30, 2021
shall not exceed Seven Million Three Hundred Forty-Seven Eighty-Five and No/100 Dollars
($7,347,085.00).
For the period July 1, 2020 through June 30, 2021, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate Two Million Eight
Hundred Sixty-Five Thousand Three Hundred Sixty-Three and No/100 Dollars ($2,865,363.00) in
Medi-Cal Federal Financial Participation (FFP); Two Million Eight Hundred Sixty-Five Thousand
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Three Hundred Sixty-Three and No/100 Dollars ($2,865,363.00) in Behavioral Health Realignment;
and One Million Six Hundred Sixteen Thousand Three Hundred Fifty-Nine and No/100 Dollars
($1,616,359.00) in other revenue sources to offset CONTRACTOR’s program costs, as set forth in
Exhibit B-1.
In no event shall the total maximum compensation for actual adult crisis
stabilization services performed at the Adult CSC under the terms and conditions of this Agreement be
in excess of Thirty-Four Million Six Hundred Fifty-Six Thousand Eight Hundred Ninety-Seven and
No/100 Dollars ($34,656,897.00) during the total five (5) year terms of this Agreement.
(2) YOUTH CSC:
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to
receive compensation based on actual cost for youth crisis stabilization services at the Youth CSC in
accordance with Exhibit B-2, “Youth Crisis Stabilization Center Budget,” attached hereto and by this
reference incorporated herein.
The maximum amount under this Agreement for the period July 1, 2016
through June 30, 2017 shall not exceed Two Million Six Hundred Forty Thousand Three Hundred
Ninety-Seven and No/100 Dollars ($2,640,397.00).
For the period July 1, 2016 through June 30, 2017, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One Million Twenty-Nine
Thousand Seven Hundred Fifty-Five and No/100 Dollars ($1,029,755.00) in Medi-Cal Federal
Financial Participation (FFP); One Million Twenty-Nine Thousand Seven Hundred Fifty-Five and
No/100 Dollars ($1,029,755.00) in Behavioral Health Realignment; and Five Hundred Eighty
Thousand Eight Hundred Eighty-Seven and No/100 Dollars ($580,887.00) in other revenue sources to
offset CONTRACTOR’s program costs, as set forth in Exhibit B-2.
The maximum amount for the period July 1, 2017 through June 30, 2018 shall
not exceed Two Million Seven Hundred Nineteen Thousand Six Hundred Fifty-Seven and No/100
Dollars ($2,719,657.00).
For the period July 1, 2017 through June 30, 2018, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One Million Sixty
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Thousand Six Hundred Sixty-Six and No/100 Dollars ($1,060,666.00) in Medi-Cal Federal Financial
Participation (FFP); One Million Sixty Thousand Six Hundred Sixty-Six and No/100 Dollars
($1,060,666.00) in Behavioral Health Realignment; and Five Hundred Ninety-Eight Thousand Three
Hundred Twenty-Four and No/100 Dollars ($598,324.00) in other revenue sources to offset
CONTRACTOR’s program costs, as set forth in Exhibit B-2.
The maximum amount for the period July 1, 2018 through June 30, 2019 shall
not exceed Two Million Eight Hundred One Thousand Two Hundred Forty-Seven and No/100 Dollars
($2,801,247.00).
For the period July 1, 2018 through June 30, 2019, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One Million Ninety-Two
Thousand Four Hundred Eighty-Six and No/100 Dollars ($1,092,486.00) in Medi-Cal Federal
Financial Participation (FFP); One Million Ninety-Two Thousand Four Hundred Eighty-Six and
No/100 Dollars ($1,092,486.00) in Behavioral Health Realignment; and Six Hundred Sixteen
Thousand Two Hundred Seventy-Four and No/100 Dollars ($616,274.00) in other revenue sources to
offset CONTRACTOR’s program costs, as set forth in Exhibit B-2.
The maximum amount for the period July 1, 2019 through June 30, 2020 shall
not exceed Two Million Eight Hundred Eighty-Five Thousand Two Hundred Eighty-Four and No/100
Dollars ($2,885,284.00).
For the period July 1, 2019 through June 30, 2020, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One Million One Hundred
Twenty-Five Thousand Two Hundred Sixty-One and No/100 Dollars ($1,125,261.00) in Medi-Cal
Federal Financial Participation (FFP); One Million One Hundred Twenty-Five Thousand Two
Hundred Sixty-One and No/100 Dollars ($1,125,261.00) in Behavioral Health Realignment; and Six
Hundred Thirty-Four Thousand Seven Hundred Sixty-Three and No/100 Dollars ($634,763.00) in
other revenue sources to offset CONTRACTOR’s program costs, as set forth in Exhibit B-2.
The maximum amount for the period July 1, 2020 through June 30, 2021 shall
not exceed Two Million Nine Hundred Seventy-One Thousand Eight Hundred Forty-Two and No/100
Dollars ($2,971,842.00).
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For the period July 1, 2020 through June 30, 2021, it is understood by
CONTRACTOR and COUNTY that CONTRACTOR estimates to generate One Million One Hundred
Fifty-Nine Thousand Eighteen and No/100 Dollars ($1,159,018.00) in Medi-Cal Federal Financial
Participation (FFP); One Million One Hundred Fifty-Nine Thousand Eighteen and No/100 Dollars
($1,159,018.00) in Behavioral Health Realignment; and Six Hundred Fifty-Three Thousand Eight
Hundred Five and No/100 Dollars ($653,805.00) in other revenue sources to offset CONTRACTOR’s
program costs, as set forth in Exhibit B-2.
In no event shall the total maximum compensation for actual youth crisis
stabilization services performed at the Youth CSC under the terms and conditions of this Agreement
be in excess of Fourteen Million Eighteen Thousand Four Hundred Twenty-Seven and No/100 Dollars
($14,018,427.00) during the total five (5) year terms of this Agreement.
(3) ACCESS LINE:
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to
receive compensation based on actual cost for Access Line services in accordance with Exhibit B-3,
“Access Line Budget,” attached hereto and by this reference incorporated herein.
The maximum contract amount under this Agreement for the Ramp Up
Period (July 1, 2016 through August 31, 2016) shall not exceed Twenty-Three Thousand Six Hundred
Seventy-Eight and No/100 Dollars ($23,678.00).
The maximum amount under this Agreement for the Initial Operating
Period (September 1, 2016 through June 30, 2017) shall not exceed Two Hundred Forty-Two
Thousand, Six Hundred Seven and No/100 Dollars ($242,607.00).
The maximum amount for the period July 1, 2017 through June 30, 2018 shall
not exceed Two Hundred Ninety-Six Thousand Eight Hundred Eighty-Three and No/100 Dollars
($296,883.00).
The maximum amount for the period July 1, 2018 through June 30, 2019 shall
not exceed Three Hundred Seven Thousand Four Hundred Forty-Five and No/100 Dollars
($307,445.00).
The maximum amount for the period July 1, 2019 through June 30, 2020 shall
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not exceed Three Hundred Eighteen Thousand Three Hundred Eighty-Four and No/100 Dollars
($318,384.00).
The maximum amount for the period July 1, 2020 through June 30, 2021 shall
not exceed Three Hundred Twenty-Nine Thousand Seven Hundred Thirteen and No/100 Dollars
($329,713.00).
In no event shall the total maximum compensation for actual Access Line
services performed under the terms and conditions of this Agreement be in excess of One Million
Three Hundred Thousand Eighty-Seven and No/100 Dollars ($1,300,087.00) during the total five (5)
year terms of this Agreement.
B. If CONTRACTOR fails to generate the Medi-Cal revenue amounts set forth as
stated above, the COUNTY shall not be obligated to pay the difference between the estimated revenue
and the actual revenue generated.
It is further understood by COUNTY and CONTRACTOR that any Medi-Cal
revenue above the amounts stated herein will be used to directly offset the COUNTY’s contribution of
funds identified in Exhibit B-1 and Exhibit B-2. The offset of funds will also be clearly identified in
monthly invoices received from CONTRACTOR as further described in Section Five (5) of this
Agreement.
Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR’s adopted rate per mile, not to exceed the IRS published
rate.
Payment shall be made upon certification or other proof satisfactory to
COUNTY’s DBH that services have actually been performed by CONTRACTOR as specified in this
Agreement.
C. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply
with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
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D. Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval
by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be
made after receipt and verification of actual expenditures incurred by CONTRACTOR for monthly
program costs, as identified in Exhibits B-1, B-2, and B-3, in the performance of this Agreement and
shall be documented to COUNTY on a monthly basis by the tenth (10th) of the month following the
month of said expenditures. The parties acknowledge that the CONTRACTOR will be performing
hiring, training, and credentialing of staff, configuring the facility and office space, and obtaining site
certification from the COUNTY Mental Health Plan (Mental Health Plan).
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month
a detailed general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL
reports and supporting documentation shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance, as further described in Section Five (5) herein.
E. COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
All final invoices, including actual cost per unit, and/or any final budget
modification requests shall be submitted by CONTRACTOR within sixty (60) days following the final
month of service for which payment is claimed. No action shall be taken by COUNTY on invoices
submitted beyond the sixty (60) day closeout period. Any compensation which is not expended by
CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
COUNTY.
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 COUNTY. The
period of time of the deferral by COUNTY shall not exceed the period of time of the State
Controller’s delay of payment to COUNTY plus forty-five (45) days.
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G. CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR’s deficiency discovered through the State
audit process and COUNTY utilization review during the course of this Agreement. At COUNTY’s
election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon
notification or shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR
shall not receive reimbursement for any units of services rendered that are disallowed or denied by the
Mental Health Plan utilization review process or through the State Department of Health Care
Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients.
H. It is understood by CONTRACTOR and COUNTY that this Agreement is
funded with mental health funds to serve individuals with serious mental illness (SMI) and serious
emotional disturbances (SED), many of whom have co-occurring substance use disorders. It is further
understood by CONTRACTOR and COUNTY that Mental Health Realignment funds shall be used to
support appropriately integrated services for co-occurring substance use disorders in the target
population, and that integrated services can be documented in crisis assessments, interventions and
progress notes documenting linkages.
5. INVOICING
A. COUNTY’s DBH shall invoice CONTRACTOR by the fifth (5th) day of each
month for the prior month’s expenditures for building maintenance, landscaping, and utilities for the
Adult CSC and for the Youth CSC, separately. CONTRACTOR shall provide payment for these
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 monthly invoicing provided by COUNTY.
B. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of
each month for the prior month’s actual services rendered at the Adult CSC and Youth CSC to
DBHInvoices@co.fresno.ca.us. CONTRACTOR shall submit one invoice for the actual services
provided at the Adult CSC and one invoice for the actual services provided at the Youth CSC. After
CONTRACTOR renders service to referred clients, CONTRACTOR shall invoice COUNTY for
payment, certify the expenditure, and submit electronic claiming data into COUNTY’s electronic
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information system for all clients, including those eligible for Medi-Cal as well as those that are not
eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. COUNTY must pay
CONTRACTOR before submitting claims to DHCS for Federal and State reimbursement for Medi-
Cal eligible clients.
C. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of
each month for the prior month’s actual operational expenditures rendered for the Access Line to
DBHInvoices@co.fresno.ca.us and DBHQualityImprovement@co.fresno.ca.us.
D. 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 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.
E. Monthly invoices shall include a client roster for the Adult CSC, Youth CSC,
and Access Line, identifying volume reported by payer group clients served (including third party
payer of services) by month and year-to-date, including percentages.
F. CONTRACTOR shall submit monthly invoices and general ledgers that itemize
the line item charges for monthly program costs (per applicable budget, as identified in Exhibits B-1
through B-3), including the cost per unit calculation based on clients served within that month, and
excluding unallowable costs. Unallowable costs such as lobbying or political donations must be
deducted from the monthly invoice reimbursements. The invoices and general ledgers will serve as
tracking tools to determine if CONTRACTOR’s program costs are in accordance with its budgeted
cost, and cost per unit negotiated by service modes compared to actual cost per unit, as set forth in
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Exhibits B-1, B-2, and B-3. The actual cost per unit will be based upon total costs and total units of
service. It will also serve for the COUNTY to certify the public funds expended for purposes of
claiming Federal and State reimbursement for the cost of Medi-Cal services and activities.
CONTRACTOR shall remit to COUNTY on a quarterly basis, separated by Adult CSC services and
Youth CSC services, a summary report of total operational costs and volume of service unit to report
the actual costs per unit compared to the negotiated rate, as identified in Exhibits B-1 and B-2, to
report interim cost per unit. The quarterly reports will be used by COUNTY to ensure compliance
with Federal and State reimbursements certified public expenditures.
G. CONTRACTOR will remit annually within ninety (90) days from June 30, a
schedule to provide the required information on published charges (PC) for all authorized direct
specialty mental health services, as applicable to the Adult CSC, Youth CSC, or both. The published
charge listing will serve as a source document to determine the CONTRACTOR’s usual and
customary charge prevalent in the public mental health sector that is used to bill the general public,
insurers or other non-Medi-Cal third party payers during the course of business operations.
H. CONTRACTOR shall submit budgets for FY 2018-19, FY 2019-20, and FY
2020-21 to the DBH Director or designee by March 1st, prior to the next FY for written review and
approval.
I. CONTRACTOR shall submit monthly staffing reports that identify all direct
service and support staff by first and last name, applicable licensure/certifications, and full time hours
worked to be used as a tracking tool to determine if CONTRACTOR’s program is staffed according to
the requirements of this Agreement.
J. CONTRACTOR must maintain such financial records for a period of seven (7)
years or until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be
responsible for any disallowances related to inadequate documentation.
K. CONTRACTOR is responsible for collection and managing data in a manner to
be determined by DHCS and the Mental Health Plan in accordance with applicable rules and
regulations. COUNTY’s electronic information system is a critical source of information for
purposes of monitoring service volume and obtaining reimbursement. CONTRACTOR must attend
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COUNTY DBH’s Business Office training on equipment reporting for assets, intangible and sensitive
minor assets, COUNTY’s electronic information system, and related cost reporting.
L. CONTRACTOR shall submit service data into County’s electronic information
system within ten (10) calendar days from the date services were rendered. Federal and State
reimbursement for Medi-Cal specialty mental health services is based on public expenditures certified
by the CONTRACTOR. CONTRACTOR must submit a signed certified public expenditure report,
one for the Adult CSC and one for the Youth CSC, with each respective monthly invoice. DHCS
expects the claims for Federal and State reimbursement to equal the amount the COUNTY paid the
CONTRACTOR for the service rendered less any funding sources not eligible for Federal and State
reimbursement.
M. CONTRACTOR must provide all necessary data to allow the COUNTY to bill
Medi-Cal, and any other third-party source, for services and meet State and Federal reporting
requirements. The necessary data can be provided by a variety of means, including but not limited to:
1) direct data entry into COUNTY’s information system; 2) providing an electronic file compatible
with COUNTY’s electronic information system; or 3) integration between COUNTY’s electronic
information system and CONTRACTOR’s information system(s).
N. If a client has other health coverage (OHC) such as private insurance or Federal
Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a
payment/denial or have validation of claiming with no response ninety (90) days after the claim was
mailed before the service can be entered into the COUNTY’s electronic information system. A copy
of explanation of benefits or CSM 1500 is required as documentation. CONTRACTOR must report
all revenue collected from OHC, third-party, client-pay or private-pay in each monthly invoice and
in the cost report that is required to be submitted. CONTRACTOR shall submit monthly invoices
for reimbursement that equal the amount due CONTRACTOR less any funding sources not eligible
for Federal and State reimbursement. CONTRACTOR must comply with all laws and regulations
governing the Federal Medicare program, including, but not limited to: 1) the requirement of the
Medicare Act, 42 U.S.C. section 1395 et seq; and 2) the regulations and rules promulgated by the
Federal Centers for Medicare and Medicaid Services as they relate to participation, coverage and
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claiming reimbursement. CONTRACTOR will be responsible for compliance as of the effective
date of each Federal, State or local law or regulation specified.
O. Data entry shall be the responsibility of the CONTRACTOR. The direct
specialty mental health services data for billing must be reconciled by the CONTRACTOR to the
monthly invoices submitted for payment. COUNTY shall monitor the volume of services and cost of
services entered into the COUNTY’s electronic information system. Any and all audit exceptions
resulting from the provision and reporting of Medi-Cal services by CONTRACTOR shall be the sole
responsibility of the CONTRACTOR. CONTRACTOR will comply with all applicable policies,
procedures, directives and guidelines regarding the use of COUNTY’s electronic information system.
P. Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR will establish and maintain Medi-Cal certification or become
certified within ninety (90) days of the effective date of this Agreement through COUNTY to provide
reimbursable services to Medi-Cal eligible clients. In addition, CONTRACTOR shall work with the
COUNTY’s DBH to execute the process if not currently certified by COUNTY for credentialing of
staff. During this process, the CONTRACTOR will obtain a legal entity number established by the
DHCS, a requirement for maintaining Mental Health Plan organizational provider status throughout
the term of this Agreement. CONTRACTOR will be required to become Medi-Cal certified prior to
providing services to Medi-Cal eligible clients and seeking reimbursement from the COUNTY.
CONTRACTOR will not be reimbursed by COUNTY for any services rendered prior to certification.
CONTRACTOR shall provide direct specialty mental health services in
accordance with the Mental Health Plan. CONTRACTOR must comply with the “Fresno County
Mental Health Plan Compliance Program and Code of Conduct” set forth in Exhibit C, attached hereto
and incorporated herein by reference and made part of this Agreement.
CONTRACTOR may provide direct specialty mental health services using
unlicensed staff as long as the individual is approved as a provider by the Mental Health Plan, is
supervised by licensed staff, works within his/her scope and only delivers allowable direct specialty
mental health services. It is understood that each service is subject to audit for compliance with
Federal and State regulations, and that COUNTY may be making payments in advance of said review.
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In the event that a service is disapproved, COUNTY may, at its sole discretion, withhold
compensation or set off from other payments due the amount of said disapproved services.
CONTRACTOR shall be responsible for audit exceptions to ineligible dates of services or incorrect
application of utilization review requirements.
6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under
this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of the 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 its obligations in accordance with the
terms and conditions thereof. CONTRACTOR and COUNTY shall comply with all applicable
provisions of law and the rules and regulations, if any, of governmental authorities having jurisdiction
over matters which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees
all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and
save COUNTY harmless from all matters relating to payment of CONTRACTOR's employees,
including compliance with Social Security, withholding, and all other regulations governing such
matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be
providing services to others unrelated to the COUNTY or to this Agreement.
7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written
consent of all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to line items in the budget, as set forth in Exhibits
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B-1 through B-3, that do not exceed ten percent (10%) of the maximum compensation payable to the
Contractor, and changes to the volume of units of services/types of service units and changes to the
service rate to be provided as set forth in Exhibits B-1 and B-2, may be made with the written
approval of COUNTY’s DBH Director or designee. Changes to line items in the budget, as set forth
in Exhibits B-1 through B-3, that exceed 10% of the maximum compensation payable to the
CONTRACTOR, may be made with the signed written approval of COUNTY’s DBH Director, or
designee, and CONTRACTOR through an amendment approved by County Counsel and the
COUNTY’s Auditor’s Controller’s Office.
In addition, changes to the scope of services and responsibilities of the CONTRACTOR,
and changes to staffing, as set forth in Exhibits A-1 through A-3 and Exhibit B-3, as needed to
accommodate changes in the law related to mental health treatment, substance use disorder treatment,
and Access Line services, may be made with the written approval of the COUNTY’s DBH Director or
designee and CONTRACTOR through an amendment approved by County Counsel and Auditor.
Said budget line item, service volume/types of service units, and scope of work changes
shall not result in any change to the maximum compensation amount payable to CONTRACTOR, as
stated herein.
8. NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY.
9. HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of CONTRACTOR, its officers, agents or employees under this Agreement.
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CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California audit
exceptions resulting from noncompliance herein on the part of the CONTRACTOR.
10. INSURANCE
Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR
or any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect the
following insurance policies throughout the term of this Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Five Million
Dollars ($5,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations,
product liability, contractual liability, Explosion, Collapse, and Underground
(XCU), fire legal liability or any other liability insurance deemed necessary
because of the nature of the Agreement.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a
combined single limit of One Million Dollars ($1,000,000). Coverage should
include owned and non-owned vehicles used in connection with this Agreement.
C. Real and Personal Property
CONTRACTOR shall maintain a policy of insurance for all risk personal
property coverage which shall be endorsed naming the County of Fresno as an
additional loss payee. The personal property coverage shall be in an amount that
will cover the total of the County purchased and owned property, at a minimum,
as discussed in Section Twenty-One (21) of this Agreement.
D. All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of
the County’s Personal Property in the possession of CONTRACTOR and/or used
in the execution of this Agreement. COUNTY will be identified on an
appropriate certificate of insurance as the certificate holder and will be named as
an Additional Loss Payee on the Property Insurance Policy.
E. Professional Liability
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If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., L.M.F.T.) in providing services, Professional Liability Insurance with
limits of not less than Two Million Dollars ($2,000,000) per occurrence, Five
Million Dollars ($5,000,000) annual aggregate. CONTRACTOR agrees that it
shall maintain, at its sole expense, in full force and effect for a period of three (3)
years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
F. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
G. Child Abuse/Molestation and Social Services Coverage
CONTRACTOR shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial Liability
policy covering Child Abuse/Molestation and Social Services Liability. The
policy limits for these policies shall be Two Million Dollars ($2,000,000) per
occurrence with Five Million Dollars ($5,000,000) annual aggregate. The
policies are to be on a per occurrence basis.
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by the COUNTY, its officers, agents and employees shall be excess only and
not contributing with insurance provided under the CONTRACTOR's policies herein. This insurance
shall not be cancelled or changed without a minimum of thirty (30) days advance written notice given
to COUNTY.
Within thirty (30) days from the date CONTRACTOR signs this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of
the foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health,
4441 E. Kings Canyon, Fresno, California, 93702, Attention: Mental Health Contracts Section, 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
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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 the 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, the COUNTY may, in addition to other remedies it may have, suspend or terminate
this Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
of A FSC VII or better.
11. LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff
shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions
necessary for the provision of the services hereunder and required by the laws and regulations of the
United States of America, State of California, the County of Fresno, and any other applicable
governmental agencies. CONTRACTOR shall notify COUNTY immediately in writing of its inability
to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions
irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR and
CONTRACTOR’s staff shall comply with all applicable laws, rules or regulations, as may now exist
or be hereafter changed.
12. RECORDS
CONTRACTOR shall maintain records in accordance with Exhibit D, “Documentation
Standards for Client Records”, attached hereto and by this reference incorporated herein and made part
of this Agreement. During site visits, COUNTY shall be allowed to review records of services
provided, including the goals and objectives of the treatment plan, and how the therapy provided is
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achieving the goals and objectives.
13. REPORTS
A. Cost Report
CONTRACTOR agrees to submit a complete and accurate detailed cost report
on an annual basis for each fiscal year ending June 30th in the format prescribed by the DHCS for the
purposes of Short Doyle Medi-Cal reimbursements and total costs for programs. CONTRACTOR
shall submit one cost report for the Adult CSC services and one cost report for the Youth CSC
services. Each cost report will be the source document for several phases of settlement with the
DHCS for the purposes of Short Doyle Medi-Cal reimbursement. CONTRACTOR shall report costs
under their approved legal entity number established during the Medi-Cal certification process. The
information provided applies to CONTRACTOR for program related costs for services rendered to
Medi-Cal and non Medi-Cal. The CONTRACTOR will remit a schedule to provide the required
information on published charges for all authorized services. The report will serve as a source
document to determine the CONTRACTOR’s usual and customary charge prevalent in the public
mental health sector that is used to bill the general public, insurers or other non Medi-Cal third party
payers during the course of business operations. CONTRACTOR must report all collections for
Medi-Cal/Medicare services and collections. CONTRACTOR shall also submit with each cost report
a copy of the CONTRACTOR’s general ledger that supports revenues and expenditures for the
specified Adult or Youth CSC. CONTRACTOR must also include a reconciled detailed report of the
total units of services rendered under this Agreement compared to the units of services entered by
CONTRACTOR to COUNTY’s electronic information system.
Cost reports must be submitted to the COUNTY as a hard copy with a signed
cover letter and electronic copy of the completed DHCS cost report form along with requested support
documents following each fiscal year ending June 30th. During the month of September of each year
this Agreement is effective, COUNTY will issue instructions of the annual cost report which indicates
the training session, DHCS cost report template worksheets, and deadlines to submit as determined by
the State annually. Remit the hard copies of the cost reports to County of Fresno, Attention: Cost
Report Team, P.O. Box 45003, Fresno, CA 93718. Remit the electronic copy or any inquiries to
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DBHcostreportteam@co.fresno.ca.us.
All Cost Reports must be prepared in accordance with General Accepted Accounting
Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3) and 5718(c).
Unallowable costs such as lobby or political donations must be deducted on the cost report and invoice
reimbursements.
If the CONTRACTOR does not submit the cost report(s) by the deadline, including any
extension period granted by the COUNTY, the COUNTY may withhold payments of pending
invoicing under compensation until the cost report(s) has been submitted and clears COUNTY desk
audit for completeness.
B. 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 and
COUNTY audit settlement findings related to the reimbursements 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-State DHCS audit:
1) initial cost reporting - after an internal review by COUNTY, the COUNTY files cost report with
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 eighteen (18) to thirty-six (36)
months following the State close of the fiscal year, DHCS will send notice for any settlement under
this provision to the COUNTY; and 3) Audit Settlement-DHCS audit. After final reconciliation and
settlement, COUNTY and/or DHCS may conduct a review of medical records, cost report along with
support documents submitted to COUNTY in initial submission to determine accuracy and may
disallow cost and/or unit of service reported on the CONTRACTOR’s legal entity cost report.
COUNTY may choose to appeal and therefore reserves the right to defer payback settlement with
CONTRACTOR until resolution of the appeal. DHCS Audits will follow federal Medicaid
procedures for managing overpayments.
If at the end of the Audit Settlement, the COUNTY determines that it overpaid
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the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related overpayment
back to the COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification
by the COUNTY, or COUNTY shall withhold future payments until all excess funds have been
recouped by means of an offset against any payments then or thereafter owing to CONTRACTOR
under this or any other Agreement.
C. Outcome Reports
CONTRACTOR shall submit to COUNTY’s DBH service outcome reports as
requested by DBH. Outcome reports and outcome requirements are subject to change at COUNTY
DBH’s discretion. CONTRACTOR shall provide outcomes as stated in Exhibits A-1, A-2, and A-3.
D. Daily Census Reports
CONTRACTOR will submit a copy of admitted clients on a daily basis to
COUNTY’s DBH Director, and/or designee, separated by the Adult CSC daily census information and
the Youth CSC daily census information. Said daily census report shall identify clients by DHCS
client identification number, Social Security number, date of birth, age, length of stay, Axis I
Diagnosis, housing status, and financial status such as Medi-Cal and/or general relief, identify client’s
primary physician status, and identify discharged clients in a format acceptable to COUNTY’s DBH
Director, or designee. Said daily census reports shall accompany each monthly invoice submitted by
CONTRACTOR.
E. Additional Reports
CONTRACTOR shall also furnish to COUNTY such statements, records,
reports, data, and other information as COUNTY’s DBH may request pertaining to matters covered by
this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments
until there is compliance. In addition, CONTRACTOR shall provide written notification and
explanation to COUNTY within five (5) days of any funds received from another source to conduct
the same services covered by this Agreement.
//
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14. MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
DHCS, or their designees, the right to review and monitor records, programs or procedures, at any
time, in regard to clients, as well as the overall operation of CONTRACTOR’s programs, in order to
ensure compliance with the terms and conditions of this Agreement.
15. REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment.
16. COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under
an agreement with DHCS, and that under said agreement the State imposes certain requirements on
COUNTY and its subcontractors. CONTRACTOR shall adhere to all State requirements, including
those identified in Exhibit E, “State Mental Health Requirements”, attached hereto and by this
reference incorporated herein and made part of this Agreement.
17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall be required to maintain Mental Health Plan organizational
provider certification by Fresno County. CONTRACTOR must meet Medi-Cal organization provider
standards as listed in Exhibit F, “Medi-Cal Organizational Provider Standards”, attached hereto and by
this reference incorporated herein and made part of this Agreement. It is acknowledged that all
references to Organizational Provider and/or Provider in Exhibit F shall refer to CONTRACTOR. In
addition, CONTRACTOR shall inform every client of their rights under the COUNTY’s Mental
Health Plan as described in Exhibit G, “Fresno County Mental Health Plan Grievances and Incident
Reporting”, attached hereto and by this reference incorporated herein. CONTRACTOR shall also file
an incident report for all incidents involving clients, following the Protocol for Completion of Incident
Report and using the “Incident Report Worksheet” both identified in Exhibit H, 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 designee.
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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 104-191(HIPAA) and agree to use and disclose Protected Health Information (PHI) as required
by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the
security of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information
Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations
promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations)
and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of
PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the
Code of Federal Regulations.
20. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
enter into a contractual relationship with the COUNTY for the purpose of providing services under
this Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR by the COUNTY, including but not limited to the following:
//
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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
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief
Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR, including its subcontractors and employees, may not use
COUNTY computers or computer peripherals on non-COUNTY premises without prior authorization
from the COUNTY’s Chief Information Officer, and/or designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive
data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY
data internally and externally.
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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
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 (1) year. Depreciation of the qualified
items will be on a straight-lien basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1. Asset must have life span of over one year.
2. The asset is not a repair part.
3. The asset must be valued at or greater than the capitalization thresholds
for the asset type:
Asset type Threshold
• land $0
• buildings and improvements $100,000
• infrastructure $100,000
• be tangible $5,000
o equipment
o vehicles
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• or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
• and capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If
it is approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed
Asset Log will be maintained by COUNTY’s Asset Management System and inventoried annually
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 One Thousand and No/100 Dollars ($1,000.00) with over a one (1) 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 shall maintain a tracking system on the items that are not
required to be capitalized or depreciated. The items are subject to annual inventory review by the
COUNTY’s DBH 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 excepted;
2. To label all items of equipment with COUNTY assigned program
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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 loss 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 Director or designee, 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 identified herein is sold and/or is utilized by CONTRACTOR for a use
which does not qualify under this program, 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 non-program funds. These requirements shall continue in effect for the life of the
property. In the event the program is closed out, the requirements for this Section 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, religious creed, color, national origin, ancestry, physical disability, mental disability, medical
condition, genetic information, marital status, sex, gender, gender identity, gender expression, age,
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sexual orientation, military status or veteran status pursuant to all applicable State of California and
Federal statutes and regulation.
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, 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.
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E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within sixty (60) days from date of contract execution, CONTRACTOR’s
plan to address all fifteen national cultural competency standards as set forth in the “National
Standards on Culturally and Linguistically Appropriate Services (CLAS)”
http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. COUNTY’s annual on-site review of
CONTRACTOR shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR’s plan must be
updated accordingly.
24. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, CONTRACTOR shall make available,
upon written request of the Secretary of the United States Department of Health and Human Services,
or upon request of the Comptroller General of the United States General Accounting Office, or any of
their duly authorized representatives, a copy of this Agreement and such books, documents, and
records as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR 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 of the Secretary of the United States
Department of Health and Human Services, or upon request of the Comptroller General of the United
States General Accounting Office, or any of their duly authorized representatives, a copy of such
subcontract and such books, documents, and records of such organization as are necessary to verify
the nature and extent of such costs.
//
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25. SINGLE AUDIT CLAUSE
A. If any 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 shall 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 audits shall be
delivered to COUNTY’s DBH Business Office for review within nine (9) months of the end of any
fiscal year in which funds were expended and/or received for the program. Failure to perform the
requisite audit functions as required by this Agreement may result in COUNTY performing the
necessary audit tasks, or at COUNTY’s option, contracting with a public accountant to perform said
audit, or may result in the inability of COUNTY to enter into future agreements with CONTRACTOR.
All audit costs related to this Agreement are the sole responsibility of 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 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 reports 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 Section shall be billed to the CONTRACTOR at COUNTY’s cost,
as determined by COUNTY’s Auditor-Controller/ Treasurer-Tax Collector.
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C. CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the
Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
period of at least three (3) years following final payment under this Agreement or the closure of all
other pending matters, whichever is later.
26. COMPLIANCE
CONTRACTOR agrees to comply with COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached hereto and by
this reference incorporated herein and made part of this Agreement . Within thirty (30) days of
entering into this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR’s
employees, agents and subcontractors providing services under this Agreement certify in writing, that
he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and
Ethics. CONTRACTOR shall ensure that within thirty (30) days of hire, all new employees, agents
and subcontractors providing services under this Agreement shall certify in writing that he or she has
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 and Ethics
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, agent 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 thirty (30) days of hire. Each individual
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
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Agreement.
27. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it or any of its officers
are not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs: that it or any of its officers have not been convicted of a criminal offense
related to the provision of health care items or services; nor has it, or 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 this Agreement, that
CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR from
responsibility for, or involvement with, COUNTY’s business operations related to the Federal Health
Care Programs and shall remove such CONTRACTOR from any position in which CONTRACTOR’s
compensation, or the items or services rendered, ordered or prescribed by CONTRACTOR may be
paid in whole or part, directly or indirectly, by Federal Health Care Programs or otherwise with
Federal Funds at least until such time as CONTRACTOR is reinstated into participation in the Federal
Health Care Programs.
A. If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term on
any contract, CONTRACTOR 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.
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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, the 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 clients.
C. CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement: (1) are not currently excluded, suspended,
debarred, 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 Programs after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs a
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 heath 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 Section One (1) of 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.
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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 clients.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits
relating to CONTRACTOR’s compliance with the provisions of this Section.
E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation of
CONTRACTOR’s obligations as described in this Section.
28. PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e.,
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
Exhibits B-1 and B-2 of this Agreement for such items as written/printed materials, the use of media
(i.e., radio, television, newspapers) and any other related expense(s).
29. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client
or a client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries
concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th) day of
the following month, in a format that is mutually agreed upon. Besides the detailed complaint log,
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.
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CONTRACTOR shall notify COUNTY of all incidents reportable to state licensing bodies that affect
COUNTY clients within twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or
corrective action taken to resolve the complaint. In addition, CONTRACTOR shall inform every
client of their rights as set forth in Exhibit G. CONTRACTOR shall file an incident report for all
incidents involving clients, following the protocol and using the worksheet identified in Exhibit H.
30. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent,
or managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101,
455.104, and 455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR by completing Exhibit I “Disclosure
of 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 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 I. Submissions shall be scanned pdf copies and are to be sent via email to
DBHAdministration@co.fresno.ca.us, Attention: Contracts Administration.
31. DISCLOSURE OF CRIMINAL HISTORY & CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them,
their owners, officers, corporate managers or partners (hereinafter collectively referred to as
“CONTRACTOR”):
A. Within the three-year period preceding the Agreement award, CONTRACTOR
has been convicted of, or had a civil judgment tendered against it for:
1. Fraud or criminal offense in connection with obtaining, attempting to
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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, CONTRACTOR
has had a public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR
from further business consideration. The information will be considered as part of the determination
of whether to continue and/or renew the Contract and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later
determined that the CONTRACTOR failed to disclose required information, any contract awarded to
such CONTRACTOR may be immediately voided and terminated for material failure to comply with
the terms and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and
Other Responsible Matters – Primary Covered Transactions” in the form set forth in Exhibit J attached
hereto and by this reference incorporated herein. Additionally CONTRACTOR must immediately
advise the COUNTY in writing if, during the term of the 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.sam.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 Responsible Matters.
32. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this agreement, the CONTRACTOR
COUNTY OF FRESNO
Fresno, CA
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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” as identified in Exhibit K,
attached hereto and by this reference incorporated herein and made part of this Agreement, and
submitting it to the COUNTY prior to commencing with the self-dealing transaction or immediately
thereafter.
33. AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours, and as often as the
COUNTY may deem necessary, make available to the COUNTY for examination all of its records and
data with respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request
by the COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to
ensure CONTRACTOR's compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor for a period of
three (3) years after final payment under contract (Government Code section 8546.7).
34. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County President and CEO
Department of Behavioral Health Exodus Recovery, Inc.
4441 E. Kings Canyon Rd 9808 Venice Boulevard, Suite 700
Fresno, CA 93702 Culver City, CA 90232
Any and all notices between the COUNTY and the CONTRACTOR provided for or
permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
COUNTY OF FRESNO
Fresno, CA
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personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
United States Mail, postage prepaid, addressed to such party.
35. GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
36. ENTIRE AGREEMENT
This Agreement, including all Exhibits between CONTRACTOR and COUNTY, RFP
No. 952-5405 and CONTRACTOR’s response thereto, 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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[N WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
year first hereinabove written.
ATTEST:
CONTRACTOR: COUNTY OF FRESNO
EXODUS RECOVERY, INC.
By ~~~~
Chatrman, Board of SuperviSors
10 Title: ~~--~~~+-+-~~~--Date: ()') ~ J... L\ , :AD ll.P
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cer, or
President, or any Vice President
By~/
:;;;ii"'·--
Print Name: l_eejfi),;) Skoro h a.:::Q
Title: ~:::·~~--=.J..:=..-.:::..!.--=-f-------
Secretary (ofCor oration), or
any Assistant Secretary, or
ChiefFinancial Officer, or
any Assistant Treasurer
Mailing Address:
Exodus Recovery, Inc.
9808 Venice Boulevard, Suite 700
Culver City, CA 90232
Contact: Luana Murphy, President/CEO
Phone: (31 0) 945-3350
BERNICE E. SEIDEL, Clerk
Board of Supervisors
Pl.EASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
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COUN'IYOJI FRESNO
hcs.no, CA
Exhibit A-1
Page 1 of 11
ADULT CRISIS STABILIZATION CENTER
Scope of Work
ORGANIZATION: Exodus Recovery, Inc.
ADDRESS: 9808 Venice Boulevard, Suite 700, Culver City, CA 90232
SITE ADDRESS: 4411 E. Kings Canyon Road, Fresno, CA 93702 (Bldg 319)
SERVICES: Adult Crisis Stabilization Services
PROJECT DIRECTOR: Luana Murphy, MBA, President/CEO
Phone Number: (559) 453-6271
CONTRACT PERIOD: July 1, 2016 – June 30, 2019, with two (2) twelve (12) month renewal options
CONTRACT AMOUNT:
Fiscal Year Contract Maximum
FY 2016-17 $6,527,765
FY 2017-18 $6,723,623
FY 2018-19 $6,925,332
FY 2019-20 $7,133,092
FY 2020-21 $7,347,085
SCHEDULE OF SERVICES:
CONTRACTOR shall operate the Adult Crisis Stabilization Center (Adult CSC) twenty-four (24) hours per day,
seven (7) days per week. The Adult CSC shall be located at the Kings Canyon Campus at 4411 E. Kings
Canyon Road, Fresno, California 93702 (Building 319), a COUNTY-owned building, pursuant to a separate
lease agreement (and any related amendments) between COUNTY and Exodus Foundation, Inc., an affiliate
of CONTRACTOR.
TARGET POPULATION:
The target population will include clients 18 years of age and older from Fresno County, who are exhibiting
acute psychiatric symptoms and have either been placed on a Welfare and Institution Code (W&IC) 5150
designation or who request admittance to the Adult CSC on a voluntary status. CONTRACTOR will provide
crisis stabilization services to adult clients with a twenty (20) bed maximum at any given time. However,
CONTRACTOR may be in the process of assessing or evaluating additional clients, as necessary.
CONTRACTOR will accept voluntary or involuntarily admitted clients regardless of source of payment;
clients will include Medi-Cal beneficiaries, Medicare and Medicare/Medi-Cal beneficiaries, privately insured
and indigent/uninsured clients who are referred by the Department of Behavioral Health (DBH), a contract
provider with the DBH, a hospital emergency room (aka emergency department), law enforcement, or
Emergency Medical Services (EMS). Clients may also be family or self-referred.
These services shall be performed pursuant to W&IC, sections 5704.5(b), 5704.6(c), and 5614(b)(3) and
program principles and the array of treatment options required under W&IC, sections 5600.2 to 5600.9
inclusive.
PROJECT DESCRIPTION:
CONTRACTOR shall be responsible to comply with the requirements of the Fresno County Mental Health Plan
(FCMHP) and must complete and submit supporting clinical and any other such documentation as may be
required by the COUNTY for every client served in the Adult CSC. The FCMHP will perform a utilization
Exhibit A-1
Page 2 of 11
review of all admissions to determine that the documentation demonstrates that medical necessity criteria as
defined by the California Department of Health Care Services (DHCS) was met for each duration of the
hospitalization, except for the episode of discharge.
CONTRACTOR shall be responsible to enter all Client Service Information, admission data and billing
information into the COUNTY data system (AVATAR) and will be responsible for any and all audit exceptions
pertaining to the delivery of services.
CONTRACTOR’S RESPONSIBILITIES:
A. CONTRACTOR shall ensure that the Adult CSC provides the following services:
1. Management and alleviation of client’s acute psychiatric symptoms through effective therapeutic
interventions and supportive services to avoid the need for a higher level of psychiatric care
when clinically appropriate.
2. A recovery/strength based clinical program which has appropriate professional staffing on a
twenty-four (24) hour, seven (7) day a week basis.
3. A safe, secure environment for clients that encourages wellness and recovery.
4. A comprehensive multi-disciplinary evaluation and client-centered treatment plan.
5. Dietary services through the availability of nourishment or snacks in accordance with Title 22,
Division 5, Chapter 9, Article 3, Section 77077.
6. Admission procedures for clients, who are not on involuntary holds in accordance with Welfare
and Institutions Code 5150 and also individuals placed on W&I 5150 involuntary holds.
7. Crisis consultation services to rural service providers (e.g. emergency departments, etc.) that
may not have timely access to the centrally located crisis stabilization facilities and may require
consultation to support client care planning and/or mitigate unnecessary long transports of clients
to the Adult CSC from remote areas. Crisis consultation may occur via teleconference, tele-
behavioral health (i.e. utilization of video and computer equipment), and/or other method
presented by CONTRACTOR and deemed acceptable by the department.
8. Treatment Planning – Under the clinical direction of the mental health clinician, the multi-
disciplinary treatment team formed by the Crisis Stabilization staff shall provide the following
services:
a. Mental Status Examination
b. Medical Evaluation
c. Full Clinical Assessment
d. Nursing Assessment
e. Multi-Disciplinary Milieu Treatment Program
f. Client Centered Treatment Planning
g. Aftercare Planning and Wellness Recovery Action Plan (WRAP)
9. Staffing
a. The staffing pattern for the crisis stabilization program shall meet all current State
licensing and regulatory requirements including medical staff standards, nursing staff
standards, social work and rehabilitation staff requirements pursuant to Title 9, Division 1,
Chapter 11, Article 3, Section 1840.348 of the California Code of Regulations (CCR) for
Exhibit A-1
Page 3 of 11
Crisis Stabilization services. All staff requiring federal/state licensure or certification will
be required to be licensed or certified in the State of California and be in good standing
with the state licensing or certification board. CONTRACTOR shall remain up-to-date with
all current regulatory changes and adhere to all new and/or modified requirements.
b. All facility staff who provide direct client care or perform coding/billing functions must meet
the requirements of the FCMHP Compliance Program. This includes the screening for
excluded persons and entities by accessing or querying the applicable licensing board(s),
the National Practitioner Data Bank (NPDB), Office of Inspector General’s List of Excluded
Individuals/Entities (LEIE), Excluded Parties List System (EPLS) and Medi-Cal Suspended
and Ineligible List prior to hire and annually thereafter. In addition, all
licensed/registered/waivered staff must complete a FCMHP Provider Application and be
credentialed by the FCMHP’s Credentialing Committee. All of CONTRACTOR’s staff who
have direct contact with the clients, shall have Department of Justice (DOJ), Federal
Bureau of Investigation (FBI), and Sheriff fingerprinting (Livescan) executed.
c. Peer and/or family support staff will be an active and key member of the multi-disciplinary
team to assist with treatment planning, mentoring, support and advocate with
clients/families during their time at the Adult CSC facility and will assist with discharge
planning and facilitate the client’s transition to the appropriate lower level of care.
d. The staffing requirements defined by CCR, Title 9, Section 1840.348 for the Adult CSC is
as follows:
(a) A physician shall be on call at all times for the provision of those Crisis Stabilization
Services that may only be provided by a physician.
(b) There shall be a minimum of one Registered Nurse, Psychiatric Technician, or
Licensed Vocational Nurse on site at all times beneficiaries are present.
(c) At a minimum there shall be a ratio of at least one licensed mental health or
waivered/registered professional on site for each four beneficiaries or other patients
receiving Crisis Stabilization at any given time.
(d) If the client is evaluated as needing service activities that can only be provided by a
specific type of licensed professional, such persons shall be available.
(e) Other persons may be utilized by the program, according to need.
(f) If Crisis Stabilization services are co-located with other specialty mental health
services, persons providing Crisis Stabilization must be separate and distinct from persons
providing other services.
(g) Persons included in required Crisis Stabilization ratios and minimums may not be
counted toward meeting ratios and minimums for other services.
e. CONTRACTOR shall submit daily staffing reports that identify all direct service and
support staff by first and last name, applicable licensure/certifications, full time hours
worked, and the licensed/waivered/registered mental health professionals to client ratio.
10. Medical Records
a. The CONTRACTOR shall maintain records in accordance with Exhibit D, “Documentation
Standards for Client Records.” During site visits, COUNTY shall be allowed to review
records of services provided, including the goals and objectives of the treatment plan, and
how the therapy provided is achieving the goals and objectives.
Exhibit A-1
Page 4 of 11
b. The CONTRACTOR will be responsible for “release of information” requests for the Adult
CSC facility and shall adhere to applicable federal and state regulations.
11. Clinical Staff - The clinical staff of CONTRACTOR shall be composed of all licensed mental
health or waivered/registered professionals as included in CCR, Title 9, Division 1, Chapter 11,
Article 3, Section 1840.348 (Crisis Stabilization Staffing Requirements).
12. Medical Staff – The medical staff shall include a physician and a registered nurse, psychiatric
technician or licensed vocational nurse and any other type of licensed professional needed to
address client needs, pursuant to CCR, Title 9, Division 1, Chapter 11, Article 3, Section
1840.348 (Crisis Stabilization Staffing Requirements).
13. Pharmaceutical Services – CONTRACTOR shall provide for medication services on an as
needed basis and the staffing must reflect this availability, pursuant to CCR, Title 9, Division 1,
Chapter 11, Article 3, Section 1840.338 (Crisis Stabilization Contact and Site Requirements) and
all other applicable federal/state regulations.
14. Assessment of Physical Health and Medical Backup Services – Pursuant to CCR, Title 9,
Division 1, Chapter 11, Article 3, Section 1840.338 (Crisis Stabilization Contact and Site
Requirements), CONTRACTOR shall provide admission history and physical examination, and
maintain a written agreement for medical services with one or more general acute care hospitals.
15. Utilization Review, Billing and Cost Report:
a. CONTRACTOR shall notify the COUNTY of any admission of a COUNTY client within
twenty-four (24) hours or the next business day in a manner approved by the COUNTY.
The notification method shall be approved by the COUNTY.
b. CONTRACTOR shall be responsible to insure that documentation in the client’s medical
record meets medical necessity criteria for the hours of service submitted to COUNTY for
reimbursement by federal intermediaries, third-party payers and other responsible parties.
c. CONTRACTOR shall enter all mental health data and billing information into the
COUNTY’s electronic information system and will be responsible for any and all audit
exceptions pertaining to the delivery of services.
d. CONTRACTOR shall submit a complete and accurate DHCS Short/Doyle Medi-Cal Cost
Report for each fiscal year ending June 30th affected by the proposed agreement within
120 days following the end of each fiscal year.
e. CONTRACTOR shall insure that cost reports are prepared in accordance with General
Accepted Accounting Principles (GAAP) and the standards set forth by the DHCS and the
COUNTY.
16. Patients’ Rights and Certification Review Hearings:
a. CONTRACTOR shall adopt and post in a conspicuous place a written policy on patient
rights in accordance with section 70707 of Title 22 of the California Code of Regulations
and section 5325.1 of the California Welfare and Institutions Code and Title 42 Code of
Federal Regulations section 438.100.
b. CONTRACTOR shall allow access to COUNTY clients by the Patients’ Rights Advocate
designated by the COUNTY.
17. Family Advocate - CONTRACTOR shall promote and allow client access to the Family Advocacy
Services representative (Family Advocate) who is contracted by the COUNTY to advocate and
assist clients, families and support systems who are seeking or receiving mental health services.
Exhibit A-1
Page 5 of 11
18. Grievances and Incident Reports
CONTRACTOR shall have all grievance forms readily available at the Adult CSC facility.
CONTRACTOR shall log all grievances and the disposition of all grievances received from a
client or a client’s family in accordance with FCMHP policies and procedures as indicated within
Exhibit G. CONTRACTOR shall provide a summary of the grievance log entries concerning
COUNTY-sponsored clients to the DBH Director, or designee, at monthly intervals, by the
fifteenth (15th) day of the following month, in a format that is mutually agreed upon.
CONTRACTOR shall post signs, provided by the COUNTY, informing clients of their right to file a
grievance and appeal.
CONTRACTOR shall notify COUNTY of all incidents or unusual occurrences reportable to state
licensing bodies that affect COUNTY clients within twenty-four (24) hours. The CONTRACTOR
shall use the Incident Report form as indicated within Exhibit H for such reporting.
Within fifteen (15) days after each grievance or incident affecting COUNTY-sponsored clients,
CONTRACTOR shall provide County with the complaint and CONTRACTOR’s disposition of, or
corrective action taken to resolve the complaint or incident.
Within fifteen (15) days after CONTRACTOR submits a corrective action plan to a California
State licensing and/or accrediting body concerning any sentinel event, as the term is defined by
the licensing or accrediting agency, and within fifteen (15) days after CONTRACTOR receives a
corrective action order from a California State licensing and/or accrediting body to address a
sentinel event, CONTRACTOR shall provide a summary of such plans and orders to COUNTY.
19. Provide a safe and secure environment to provide for clinical and medical assessment,
diagnostic formulation, crisis intervention, medication management, and clinical treatment for
mental health clients with acute psychiatric symptoms. This includes the manner in which
seclusion and restraint will be administered when necessary for the safety of the clients, other
clients in the program, and staff.
20. Provide the appropriate type and level of staffing to provide for a clinically effective program
design that adheres to State staffing requirements.
21. Provide staff training in the areas of non-violent crisis intervention, evidence-based practice, best
practice, or promising practices to insure staff are competent and proficient in the therapeutic
interventions and practices in serving adult clients accessing the Adult CSC.
22. CONTRACTOR shall utilize cost containment strategies for the provision of stock and
prescription medications to clients (i.e. by contracting with a pharmaceutical benefits
management company) and provide the COUNTY with the type of formulary utilized by the
program as well as information regarding co-pays and/or generic substitutions.
23. Provide an intensive treatment program which has individualized treatment plans.
24. Stabilize the clients’ acute psychiatric symptoms in the most expedient manner possible while
adhering to appropriate clinical care standards. This may include initiating a Treatment
Authorization Request (TAR) to the pharmacy and providing justification when psychotropic
medications are needed on an emergency basis.
25. Effectively partner with other programs in the COUNTY and community system (i.e. law
enforcement, local emergency departments, etc.) in accepting COUNTY clients for admission for
crisis stabilization services.
26. Effectively partner with rural services providers (i.e. emergency departments, etc.) to provide
crisis stabilization services via teleconference, tele-behavioral health (i.e. utilization of video and
computer equipment), and/or other method deemed acceptable by COUNTY.
Exhibit A-1
Page 6 of 11
27. Work collaboratively with the COUNTY and community resources in discharge planning to
ensure appropriate referral and direct linkage to ongoing outpatient specialty mental health
treatment services, substance use disorder treatment services, etc. are provided. Discharge
planning would also include working collaboratively with out-of-county Mental Health Plans to
ensure clients in foster care who reside within Fresno County are linked to appropriate ongoing
specialty mental health services, substance use disorder treatment services, etc. as appropriate.
28. Identify clients with frequent admissions during the fiscal year and develop strategies with other
COUNTY and community agencies to reduce readmissions and improve clients’ overall well-
being through coordination of care.
29. Effectively interact with community agencies, other mental health programs and providers,
natural support systems, and families to assist clients to be discharged to the appropriate level of
care.
30. Work effectively with the DBH Conservatorship Team as appropriate for clients presenting to the
Adult CSC as gravely disabled who may require consideration for a temporary conservatorship.
31. Integrate mental health and substance use disorder services. The CONTRACTOR shall perform
the following:
a. Develop a formal written Continuous Quality Improvement CQI action plan to identify
measurable objectives toward the achievement of co-occurring disorders (COD) treatment
capability that will be addressed by the program during the contract period. These objectives
should be achievable and realistic for the program, based on a self-assessment and the
program priorities, but need to include attention to making progress on the following issues, at
minimum:
1. Welcoming policies, practices, and procedures related to the engagement of
individuals with co-occurring issues and disorders;
2. Removal or reduction of access barriers to admission based on co-occurring diagnosis
or medication;
3. Improvement in routine integrated screening, and identification in the data system of
how many clients served have co-occurring issues;
4. Developing the goal of basic co-occurring competency for all treatment and support
staff, regardless of licensure or certification, and
5. Documentation of coordination of care with collaborative mental health and/or
substance use disorder providers for each client.
B. Regarding cultural and linguistic competence requirements, CONTRACTOR shall:
1. Ensure compliance with Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45
C.F.R. Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial
assistance from discriminating against persons based on race, color, national origin, sex,
disability or religion. This is interpreted to mean that a limited English proficient (LEP) individual is
entitled to equal access and participation in federally funded programs through the provision of
comprehensive and quality bilingual services.
2. Create and maintain policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP 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 subcontracted providers with these requirements.
Exhibit A-1
Page 7 of 11
3. Ensure that minors shall not be used as interpreters.
4. Conduct and submit to COUNTY an annual cultural and linguistic needs assessment to promote
the provision and utilization of appropriate services for its diverse client population. The needs
assessment report shall include findings and a plan outlining the proposed services to be
improved or implemented as a result of the assessment findings, with special attention to
addressing cultural and linguistic barriers and reducing racial, ethnic, language, abilities, gender,
and age disparities.
5. Develop internal systems to meet the cultural and linguistic needs of the CONTRACTOR’s client
census including the incorporation of cultural competency in the CONTRACTOR’s mission;
establishing and maintaining a process to evaluate and determine the need for special -
administrative, clinical, welcoming, billing, etc. - initiatives related to cultural competency.
6. Develop recruitment and retention initiatives to establish contracted program staffing that is
reflective and responsive to the needs of the program and target population.
7. Establish designated staff person to coordinate and facilitate the integration of cultural
competency guidelines and attend COUNTY’s DBH Cultural Diversity Committee scheduled
meetings. The designated person will provide an array of communication tools to distribute
information to staff relating to cultural competency issues.
8. Keep abreast of evidence-based and best practices in cultural competency in mental health care
and treatment to ensure that the CONTRACTOR maintains current information and an external
perspective in its policies. The CONTRACTOR shall evaluate the effectiveness of strategies and
programs in improving the health status of cultural-defined populations.
9. Ensure that an assessment of a client’s sexual orientation is included in the bio-psychosocial
intake process. CONTRACTOR’s staff shall assume that the population served may not be in
heterosexual relationships. Sensitivity to gender and sexual orientation must be covered in
annual training.
10. Utilize existing community supports, referrals to transgender support groups, etc., when
appropriate.
11. Attend annual Cultural Competence, Compliance, Health Insurance Portability and Accountability
Act (HIPAA), Billing, and Documentation training provided by COUNTY’s DBH.
12. Report its efforts to evaluate cultural and linguistic activities as part of the CONTRACTOR’s
ongoing quality improvement efforts in the monthly activities report. Reported information may
include clients’ complaints and grievances, any resulting actions regarding complaints and
grievances, results from client satisfaction surveys, and utilization and other clinical data that may
reveal health disparities as a result of cultural and linguistic barriers.
C. Regarding Conservatees, CONTRACTOR agrees to the following:
CONTRACTOR shall work with COUNTY’s DBH Client Placement Team to find placement for
COUNTY conservatees that are discharged from the CONTRACTOR-operated Adult CSC.
D. Regarding direct admissions to the Adult CSC from COUNTY’s DBH programs or its contracted
providers, the CONTRACTOR agrees to the following:
1. To allow direct admits from COUNTY’s DBH programs or its contracted providers when the Adult
CSC has the capacity to accept clients for services.
2. Said direct admits shall not require medical clearance, if client would otherwise meet the
Emergency Medical Services 5150 Destination Policy requirements as mentioned hereinbelow in
Exhibit A-1
Page 8 of 11
Subsection F. However, in the event a referred client is known to possess a contagious medical
condition, said patient shall be medically cleared by a local hospital prior to admission to the Adult
CSC operated by CONTRACTOR.
E. Regarding the placement of a client at another designated facility:
1. CONTRACTOR shall notify COUNTY DBH when a client will remain at the CSC for a period in
excess of 24 hours, while awaiting placement and/or transportation. The COUNTY’s Patients
Rights Advocate will be included in this notification
2. CONTRACTOR shall provide the following services to clients who remain at the CSC for a period
in excess of 24 hours and who are awaiting placement and/or transportation:
a. Three meal periods and three snack times per 24 hours
b. Daily encouragement and support with activities of daily living i.e. showering, washing of
clothes, teeth brushing, hair combing etc.
c. Daily psychiatric evaluation by both the provider and licensed nursing staff to
evaluate/determine the clients most appropriate level of care
d. Daily medication evaluation, administration and education
e. Daily group activities (e.g. 12-Step Meetings, WRAP, Goals Group, etc.)
f. Daily one-on-one peer support provided by designated Peer Advocate
g. Daily activities such as meditation, art, entertainment and outdoor activities provided in the
outside courtyard
h. Daily education in relation to mental health diagnosis, treatments, and community resources
.
F. Regarding the provision of court testimony related to Adult CSC clients, CONTRACTOR agrees to
the following:
CONTRACTOR’s staff shall provide court testimony relevant to Adult CSC clients, when required.
G. Regarding the Emergency Medical Services (EMS) 5150 Destination Policy, CONTRACTOR
agrees to the following:
CONTRACTOR agrees to follow the then-current Emergency Medical Services 5150 Destination
Policy as identified in Exhibit L, attached hereto and incorporated herein. Said policy may be
updated periodically throughout the term of this Agreement; CONTRACTOR must adhere to the
most recent policies designated by the EMS 5150 Destination Policy. References to the
Children’s Crisis Assessment Intervention Resolution (CCAIR) Unit in Exhibit L reflect services to
be performed by CONTRACTOR at the COUNTY’s Youth CSC
H. CONTRACTOR shall participate in the following meetings:
1. CONTRACTOR shall participate in periodic workgroup meetings scheduled by staff from
COUNTY’s DBH Mental Health Contracted Services Unit. The meetings shall be held monthly, or
as needed, to discuss contract requirements, data reporting, outcomes measurement, training,
policies and procedures, and overall program operations.
2. CONTRACTOR’s administrative level agency representative, who is duly authorized to act on
behalf of CONTRACTOR, shall attend regularly scheduled monthly Behavioral Health Board
meetings.
Exhibit A-1
Page 9 of 11
3. CONTRACTOR shall attend quarterly or periodic DBH Contractor/Provider Meetings, as
scheduled by staff from COUNTY’s Mental Health Contracted Services Unit, when deemed
necessary by the DBH Director, or designee.
4. CONTRACTOR may also be asked to make presentations in the community about the program
and services that are available.
I. Regarding the development of policies and protocols:
CONTRACTOR and COUNTY’s DBH shall collaborate on the development of specific policies
and protocols related to the daily operation of the Adult CSC. Such policies will include, but not
be limited to, the following: placement of adults in psychiatric health facilities or other inpatient
programs either locally or outside the county, facility limitations, and special client populations.
Such policies and protocols shall be mutually agreed upon between CONTRACTOR and
COUNTY’s DBH Director, or designee. Any changes to such policies and protocols shall be
mutually agreed upon between CONTRACTOR and COUNTY’s DBH Director, or designee.
PROGRAM OUTCOMES
The Department of Behavioral Health is dedicated to supporting the wellness of individuals, families and
communities in Fresno County who are affected by, or at the risk of, mental illness and/or substance use
disorders through cultivation of strengths toward promoting recovery in the least restrictive environment.
Five (5) Work Plans will be utilized to support DBH’s mission statement. The work plans were developed as
a concept of a Transformation Plan that would encompass system planning, implementation and oversight
to be reflective of a comprehensive system of care. These work plans are provided below and represent
program goals to be achieved by CONTRACTOR in addition to CONTRACTOR-developed outcomes. DBH
may adjust the outcome measurements needed under this program periodically, so as to best measure the
success of clients and program as determined by the County.
CONTRACTOR will utilize a computerized tracking system with which outcome measures and other
relevant consumer data, such as demographics, will be maintained.
1. Behavioral Health Integrated Access – timeliness between client referral to admission, admission
to treatment, and treatment to discharge; penetration rate; effectiveness of discharge planning as
demonstrated by referral and linkage to other DBH programs, community providers, and other
community resources; and services that provide screening and access to ensure clients are linked to
the services they need, including mental health substance use disorders and physical health
services.
2. Wellness, Recovery, and Resiliency Supports – collaborative approach to treatment strategies to
reduce readmission of consumers with frequent admissions to the facility; effectiveness of services
as demonstrated by the number of consumers who are able to be discharged to the community and
avoid inpatient hospitalization; measurement of recidivism rates, including measuring percentage of
recidivism within 30 days. State the Evidence Based Practices (EBP) that shall be used.
3. Cultural/Community Defined Practices – services or philosophical practices which support the
unique cultural-specific needs of individuals receiving care. Focus on behavioral health practices
which reflect the unique needs of various cultures and communities who reside within Fresno
County.
4. Behavioral Health Clinical Care – services where direct therapeutic treatment is provided. Include
the framework of “Levels of Care” where client’s needs, as identified through assessment/screening,
are matched with a complexity and intensity of services meets those needs.
Exhibit A-1
Page 10 of 11
5. Infrastructure Supports – includes all personnel, equipment, programs, and facilities which exist to
support the delivery of care to the clients served. Includes safety, quality improvement and
regulatory compliance functions, along with outcome assessment/program evaluation, training, and
technology.
6. Denial rate for Crisis Stabilization billing will be decreased by 5% within the first six months, based on
previous program denial rates. Rates will be determined by the utilization review performed by
FCMHP.
COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Perform a utilization review, annually at a minimum, (through its FCMHP) of ten percent (10%) of all
admissions to determine that the documentation demonstrates that medical necessity criteria as defined
by the DHCS were met throughout the duration of the crisis stabilization episode. The FCMHP will
maintain discretion regarding possible subsequent utilization review beyond ten percent (10%), as
necessary.
2. Provide oversight of the CONTRACTOR’s Adult CSC program. In addition to contract monitoring of
program(s), oversight includes, but is not limited to, coordination with the DHCS in regard to program
administration and outcomes.
3. Assist the CONTRACTOR in making linkages to the appropriate level of care within the behavioral
health system of care to insure continuity of care. This will be accomplished through regularly
scheduled meetings as well as formal and informal consultation.
4. Participate in evaluating the progress of the overall program and the efficiency of collaboration with the
CONTRACTOR staff and will be available to the contractor for ongoing consultation.
5. Receive and analyze statistical outcome data from CONTRACTOR throughout the term of contract on a
monthly basis. DBH will notify the CONTRACTOR when additional participation is required. The
performance outcome measurement process will not be limited to survey instruments but will also
include, as appropriate, client and staff interviews, chart reviews, and other methods of obtaining
required information.
6. Recognize that cultural competence is a goal toward which professionals, agencies, and systems should
strive. Becoming culturally competent is a developmental process and incorporates at all levels the
importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that
result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to
meet culturally-unique needs. Offering those services in a manner that fails to achieve its intended
result due to cultural and linguistic barriers is not cost effective. To assist the CONTRACTOR’s efforts
towards cultural and linguistic competency, DBH shall provide the following at no cost to
CONTRACTOR:
A. Mandatory cultural competency training including sexual orientation and sensitivity training for
CONTRACTOR personnel, at minimum once per year. COUNTY will provide mandatory training
regarding the special needs of this diverse population and will be included in the cultural
competence training(s). Sexual orientation and sensitivity to gender differences is a basic cultural
competence principle and shall be included in the cultural competency training. Literature suggests
that the mental health needs of lesbian, gay, bisexual, transgender (LGBT) individuals may be at
increased risk for mental disorders and mental health problems due to exposure to societal
stressors such as stigmatization, prejudice and anti-gay violence. Social support may be critical for
this population. Access to care may be limited due to concerns about providers’ sensitivity to
differences in sexual orientation.
Exhibit A-1
Page 11 of 11
B. Assistance to CONTRACTOR in locating appropriate providers who can translate behavioral health
and substance abuse services information into COUNTY’s threshold languages (English, Spanish,
and Hmong). Translation services and costs associated will be the responsibility of the
CONTRACTOR.
Exhibit A-2
Page 1 of 11
YOUTH CRISIS STABILIZATION CENTER
Scope of Work
ORGANIZATION: Exodus Recovery, Inc.
ADDRESS: 9808 Venice Boulevard, Suite 700, Culver City, CA 90232
SITE ADDRESS: 4411 E. Kings Canyon Road, Fresno, CA, 93702 (Bldg 319)
SERVICES: Youth Crisis Stabilization Services
PROJECT DIRECTOR: Luana Murphy, MBA, President/CEO
Phone Number: (559) 453-6271
CONTRACT PERIOD: July 1, 2016 – June 30, 2019, with two (2) twelve (12) month renewal options
CONTRACT AMOUNT:
Fiscal Year Contract Maximum
FY 2016-17 $2,640,397
FY 2017-18 $2,719,657
FY 2018-19 $2,801,247
FY 2019-20 $2,885,284
FY 2020-21 $2,971,842
SCHEDULE OF SERVICES:
CONTRACTOR shall operate the Youth Crisis Stabilization Center (Youth CSC) twenty-four (24) hours per
day, seven (7) days per week. The Youth CSC shall be located at the Kings Canyon Campus at 4411 E. Kings
Canyon Road, Fresno, California 93702 (Building 319), a COUNTY-owned building, pursuant to a separate
lease agreement (and any related amendments) between COUNTY and Exodus Foundation, Inc., an affiliate
of CONTRACTOR.
TARGET POPULATION:
The target population will include children and youth up to 18 years of age from Fresno County, who are
exhibiting acute psychiatric symptoms and have either been placed on a Welfare and Institutions Code
(W&IC) 5150 designation or who request admittance to the Youth CSC on a voluntary status.
CONTRACTOR will provide crisis stabilization services to children and youth clients with an eight (8) bed
maximum at any given time. However, CONTRACTOR may be in the process of assessing or evaluating
additional clients, as necessary. CONTRACTOR will accept voluntary or involuntarily admitted clients
regardless of source of payment; clients may include Medi-Cal beneficiaries, Medicare and Medicare/Medi-
Cal beneficiaries, privately insured and indigent/uninsured clients who are referred by the Department of
Behavioral Health (DBH), a contract provider with the DBH, a hospital emergency department, law
enforcement, or Emergency Medical Services (EMS). Clients may also be family or self-referred. The Youth
CSC will also serve foster children and youth who reside in Fresno County and remain under the original
jurisdiction of another county.
These services shall be performed pursuant to W&IC, sections 5704.5(b), 5704.6(c), and 5614(b)(3) and
program principles and the array of treatment options required under W&IC, sections 5600.2 to 5600.9
inclusive.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is the child health component of Medicaid.
Federal statutes and regulations state that children under age 21 who are enrolled in Medicaid are entitled to
Exhibit A-2
Page 2 of 11
EPSDT benefits and that States must cover a broad array of preventive and treatment services to include
crisis stabilization. The requirement is to maintain its funding for children’s services at a level equal to or
more than the proportion expended for children’s program services in FY 83-84.
PROJECT DESCRIPTION:
CONTRACTOR shall be responsible to comply with the requirements of the Fresno County Mental Health Plan
(FCMHP) and must complete and submit supporting clinical and any other such documentation as may be
required by the COUNTY for every client served in the Youth CSC. The FCMHP will perform a utilization
review of all admissions to determine that the documentation demonstrates that medical necessity criteria as
defined by the California Department of Health Care Services (DHCS) was met for each duration of the crisis
stabilization services claimed for reimbursement.
CONTRACTOR shall be responsible to enter all Client Service Information, admission data and billing
information into the COUNTY data system (AVATAR) and will be responsible for any and all audit exceptions
pertaining to the delivery of services.
CONTRACTOR’S RESPONSIBILITIES:
A. CONTRACTOR shall ensure that the Youth CSC provides the following services:
1. Management and alleviation of client’s acute psychiatric symptoms through effective therapeutic
interventions and supportive services to avoid the need for a higher level of psychiatric care
when clinically appropriate.
2. A recovery/strength based clinical program which has appropriate professional staffing on a
twenty-four (24) hour, seven (7) day a week basis.
3. A safe, secure environment for clients that encourages wellness and recovery.
4. A comprehensive multi-disciplinary evaluation and client-centered treatment plan.
5. Dietary services through the availability of nourishment or snacks in accordance with Title 22,
Division 5, Chapter 9, Article 3, Section 77077.
6. Admission procedures for clients, who are not on involuntary holds in accordance with Welfare
and Institutions Code 5150 and also individuals placed on W&I 5150 involuntary holds.
7. Crisis consultation services to rural service providers (e.g. emergency departments, etc.) that
may not have timely access to the centrally located crisis stabilization facilities and may require
consultation to support client care planning and/or mitigate unnecessary long transports of clients
to the Youth CSC from remote areas. Crisis consultation may occur via teleconference, tele-
behavioral health (i.e. utilization of video and computer equipment), and/or other method
presented by CONTRACTOR and deemed acceptable by the department.
8. Treatment Planning – Under the clinical direction of the mental health clinician, the multi-
disciplinary treatment team formed by the Youth Crisis Stabilization staff shall provide the
following services:
a. Mental Status Examination
b. Medical Evaluation
c. Full Clinical Assessment
d. Nursing Assessment
e. Multi-Disciplinary Milieu Treatment Program
Exhibit A-2
Page 3 of 11
f. Client Centered Treatment Planning
g. Aftercare Planning and Wellness Recovery Action Plan (WRAP)
9. Staffing
a. The staffing pattern for the crisis stabilization program shall meet all current State
licensing and regulatory requirements including medical staff standards, nursing staff
standards, social work and rehabilitation staff requirements pursuant to Title 9, Division 1,
Chapter 11, Article 3, Section 1840.348 of the California Code of Regulations (CCR) for
Crisis Stabilization services. All staff requiring federal/state licensure or certification will
be required to be licensed or certified in the State of California and be in good standing
with the state licensing or certification board. CONTRACTOR shall remain up-to-date with
all current regulatory changes and adhere to all new and/or modified requirements.
b. All facility staff who provide direct client care or perform coding/billing functions must meet
the requirements of the FCMHP Compliance Program. This includes the screening for
excluded persons and entities by accessing or querying the applicable licensing board(s),
the National Practitioner Data Bank (NPDB), Office of Inspector General’s List of Excluded
Individuals/Entities (LEIE), Excluded Parties List System (EPLS) and Medi-Cal Suspended
and Ineligible List prior to hire and annually thereafter. In addition, all
licensed/registered/waivered staff must complete a FCMHP Provider Application and be
credentialed by the FCMHP’s Credentialing Committee. All of CONTRACTOR’s staff who
will have direct contact with the clients, shall have Department of Justice (DOJ), Federal
Bureau of Investigation (FBI), and Sheriff fingerprinting (Livescan) executed.
c. Peer and/or family support staff will be an active and key member of the multi-disciplinary
team to assist with treatment planning, mentoring, support and advocate with
clients/families during their time at the YOUTH CSC facility and will assist with discharge
planning and facilitate the client’s transition to the appropriate lower level of care.
d. At the time of execution of this Agreement, the staffing requirements defined by the
California Code of Regulations, Title 9, Section 1840.348 for the Youth CSC are as
follows:
(a) A physician shall be on call at all times for the provision of those Crisis Stabilization
Services that may only be provided by a physician.
(b) There shall be a minimum of one Registered Nurse, Psychiatric Technician, or
Licensed Vocational Nurse on site at all times beneficiaries are present.
(c) At a minimum there shall be a ratio of at least one licensed mental health or
waivered/registered professional on site for each four beneficiaries or other patients
receiving Crisis Stabilization at any given time.
(d) If the client is evaluated as needing service activities that can only be provided by a
specific type of licensed professional, such persons shall be available.
(e) Other persons may be utilized by the program, according to need.
(f) If Crisis Stabilization services are co-located with other specialty mental health
services, persons providing Crisis Stabilization must be separate and distinct from persons
providing other services.
(g) Persons included in required Crisis Stabilization ratios and minimums may not be
counted toward meeting ratios and minimums for other services.
Exhibit A-2
Page 4 of 11
e. CONTRACTOR shall submit daily staffing reports that identify all direct service and
support staff by first and last name, applicable licensure/certifications, full time hours
worked, and the licensed/waivered/registered mental health professionals to client ratio.
10. Medical Records
a. The CONTRACTOR shall maintain records in accordance with Exhibit D, “Documentation
Standards for Client Records.” During site visits, COUNTY shall be allowed to review
records of services provided, including the goals and objectives of the treatment plan, and
how the therapy provided is achieving the goals and objectives.
b. The CONTRACTOR will be responsible for “release of information” requests for the Youth
CSC facility and shall adhere to applicable federal and state regulations.
11. Clinical Staff - The clinical staff of CONTRACTOR shall be composed of all licensed mental
health or waivered/registered professionals as included in CCR, Title 9, Division 1, Chapter 11,
Article 3, Section 1840.348 (Crisis Stabilization Staffing Requirements).
12. Medical Staff – The medical staff shall include a physician and a registered nurse, psychiatric
technician or licensed vocational nurse and any other type of licensed professional needed to
address client needs pursuant to CCR, Title 9, Division 1, Chapter 11, Article 3, Section
1840.348 (Crisis Stabilization Staffing Requirements).
13. Pharmaceutical Services – CONTRACTOR shall provide for medication services on an as
needed basis and the staffing must reflect this availability pursuant to CCR, Title 9, Division 1,
Chapter 11, Article 3, Section 1840.338 (Crisis Stabilization Contact and Site Requirements) and
all other applicable federal/state regulations. The administration of a psychotropic medication(s)
to children and youth in the Foster Care System will adhere to federal/state regulations, the
requirements of pharmaceutical vendors and the coordination with the Department of Social
Services-Child Welfare as it relates to the completion of forms, provision of information, etc.
14. Assessment of Physical Health and Medical Backup Services – Pursuant to CCR, Title 9,
Division 1, Chapter 11, Article 3, Section 1840.338 (Crisis Stabilization Contact and Site
Requirements), CONTRACTOR shall provide admission history and physical examination, and
maintain a written agreement for medical services with one or more general acute care hospitals.
15. Utilization Review, Billing and Cost Report:
a. CONTRACTOR shall notify the COUNTY of any admission of a COUNTY client within
twenty-four (24) hours or the next business day in a manner approved by the COUNTY.
The notification method shall be approved by the COUNTY.
b. CONTRACTOR shall be responsible to insure that documentation in the client’s medical
record meets medical necessity criteria for the hours of service submitted to COUNTY for
reimbursement by federal intermediaries, third-party payers and other responsible parties.
c. CONTRACTOR shall enter all mental health data and billing information into the
COUNTY’s electronic information system and will be responsible for any and all audit
exceptions pertaining to the delivery of services.
d. CONTRACTOR shall submit a complete and accurate DHCS Short/Doyle Medi-Cal Cost
Report for each fiscal year ending June 30th affected by the proposed agreement within
120 days following the end of each fiscal year.
e. CONTRACTOR shall insure that cost reports are prepared in accordance with General
Accepted Accounting Principles (GAAP) and the standards set forth by the DHCS and the
COUNTY.
Exhibit A-2
Page 5 of 11
16. Patients’ Rights and Certification Review Hearings:
a. CONTRACTOR shall adopt and post in a conspicuous place a written policy on patient
rights in accordance with section 70707 of Title 22 of the California Code of Regulations
and section 5325.1 of the California W&IC and Title 42 Code of Federal Regulations
section 438.100.
b. CONTRACTOR shall allow access to COUNTY clients by the Patients’ Rights Advocate
designated by the COUNTY.
17. Family Advocate - CONTRACTOR shall promote and allow client access to the Family Advocacy
Services representative (Family Advocate) who is contracted by the COUNTY to advocate and
assist clients, families and support systems who are seeking or receiving mental health services.
18. Grievances and Incident Reports
CONTRACTOR shall have all grievance forms readily available at the Youth CSC facility.
CONTRACTOR shall log all grievances and the disposition of all grievances received from a
client or a client’s family in accordance with FCMHP policies and procedures as indicated within
Exhibit G. CONTRACTOR shall provide a summary of the grievance log entries concerning
COUNTY-sponsored clients to the DBH Director, or designee, at monthly intervals, by the
fifteenth (15th) day of the following month, in a format that is mutually agreed upon.
CONTRACTOR shall post signs, provided by the COUNTY, informing clients of their right to file a
grievance and appeal.
CONTRACTOR shall notify COUNTY of all incidents or unusual occurrences reportable to state
licensing bodies that affect COUNTY clients within twenty-four (24) hours. The CONTRACTOR
shall use the Incident Report form as indicated within Exhibit H for such reporting.
Within fifteen (15) days after each grievance or incident affecting COUNTY-sponsored clients,
CONTRACTOR shall provide County with the complaint and CONTRACTOR’s disposition of, or
corrective action taken to resolve the complaint or incident.
Within fifteen (15) days after CONTRACTOR submits a corrective action plan to a California
State licensing and/or accrediting body concerning any sentinel event, as the term is defined by
the licensing or accrediting agency, and within fifteen (15) days after CONTRACTOR receives a
corrective action order from a California State licensing and/or accrediting body to address a
sentinel event, CONTRACTOR shall provide a summary of such plans and orders to COUNTY.
19. Provide a safe and secure environment to provide for clinical and medical assessment,
diagnostic formulation, crisis intervention, medication management, and clinical treatment for
mental health clients with acute psychiatric symptoms. This includes the manner in which
seclusion and restraint will be administered when necessary for the safety of the clients, other
clients in the program, and staff.
20. Provide the appropriate type and level of staffing to provide for a clinically effective program
design that adheres to State staffing requirements.
21. Provide staff training in the areas of non-violent crisis intervention, evidence-based practice, best
practice, or promising practices to insure staff are competent and proficient in the therapeutic
interventions and practices in serving youth clients accessing the Youth CSC.
22. CONTRACTOR shall utilize cost containment strategies for the provision of stock and
prescription medications to clients (i.e. by contracting with a pharmaceutical benefits
management company) and provide the COUNTY with the type of formulary utilized by the
program as well as information regarding co-pays and/or generic substitutions.
Exhibit A-2
Page 6 of 11
23. Provide an intensive treatment program which has individualized treatment plans.
24. Stabilize the clients’ acute psychiatric symptoms in the most expedient manner possible while
adhering to appropriate clinical care standards. This may include initiating a Treatment
Authorization Request (TAR) to the pharmacy and providing justification when psychotropic
medications are needed on an emergency basis.
25. Effectively partner with other programs in the COUNTY and community system (i.e. law
enforcement, local emergency departments, etc.) in accepting COUNTY clients for admission for
crisis stabilization services.
26. Effectively partner with rural services providers (i.e. emergency departments, etc.) to provide
crisis stabilization services via teleconference, tele-behavioral health (i.e. utilization of video and
computer equipment), and/or other method deemed acceptable by COUNTY.
27. Work collaboratively with the COUNTY and community resources in discharge planning to
ensure appropriate referral and direct linkage to ongoing outpatient specialty mental health
treatment services, substance use disorder treatment services, etc. are provided. Discharge
planning would also include working collaboratively with out-of-county Mental Health Plans to
ensure clients in foster care who reside within Fresno County are linked to appropriate ongoing
specialty mental health services, substance use disorder treatment services, etc. as appropriate.
28. Identify clients with frequent admissions during the fiscal year and develop strategies with other
COUNTY and community agencies to reduce readmissions and improve clients’ overall well-
being through coordination of care.
29. Effectively interact with community agencies, other mental health programs and providers,
natural support systems, and families to assist clients to be discharged to the appropriate level of
care.
30. Integrate mental health and substance use disorder services. The CONTRACTOR shall perform
the following:
a. Develop a formal written Continuous Quality Improvement CQI action plan to identify
measurable objectives toward the achievement of co-occurring disorders (COD) treatment
capability that will be addressed by the program during the contract period. These objectives
should be achievable and realistic for the program, based on a self-assessment and the
program priorities, but need to include attention to making progress on the following issues, at
minimum:
1. Welcoming policies, practices, and procedures related to the engagement of
individuals with co-occurring issues and disorders;
2. Removal or reduction of access barriers to admission based on co-occurring diagnosis
or medication;
3. Improvement in routine integrated screening, and identification in the data system of
how many clients served have co-occurring issues;
4. Developing the goal of basic co-occurring competency for all treatment and support
staff, regardless of licensure or certification, and
5. Documentation of coordination of care with collaborative mental health and/or
substance use disorder providers for each client.
Exhibit A-2
Page 7 of 11
B. Regarding cultural and linguistic competence requirements, CONTRACTOR shall:
1. Ensure compliance with Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45
C.F.R. Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial
assistance from discriminating against persons based on race, color, national origin, sex,
disability or religion. This is interpreted to mean that a limited English proficient (LEP) individual
is entitled to equal access and participation in federally funded programs through the provision of
comprehensive and quality bilingual services.
2. Create and maintain policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP 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 subcontracted providers with these requirements.
3. Ensure that minors shall not be used as interpreters.
4. Conduct and submit to COUNTY an annual cultural and linguistic needs assessment to promote
the provision and utilization of appropriate services for its diverse client population. The needs
assessment report shall include findings and a plan outlining the proposed services to be
improved or implemented as a result of the assessment findings, with special attention to
addressing cultural and linguistic barriers and reducing racial, ethnic, language, abilities, gender,
and age disparities.
5. Develop internal systems to meet the cultural and linguistic needs of the CONTRACTOR’s client
census including the incorporation of cultural competency in the CONTRACTOR’s mission;
establishing and maintaining a process to evaluate and determine the need for special -
administrative, clinical, welcoming, billing, etc. - initiatives related to cultural competency.
6. Develop recruitment and retention initiatives to establish contracted program staffing that is
reflective and responsive to the needs of the program and target population.
7. Establish designated staff person to coordinate and facilitate the integration of cultural
competency guidelines and attend COUNTY’s DBH Cultural Diversity Committee scheduled
meetings. The designated person will provide an array of communication tools to distribute
information to staff relating to cultural competency issues.
8. Keep abreast of evidence-based and best practices in cultural competency in mental health care
and treatment to ensure that the CONTRACTOR maintains current information and an external
perspective in its policies. The CONTRACTOR shall evaluate the effectiveness of strategies and
programs in improving the health status of cultural-defined populations.
9. Ensure that an assessment of a client’s sexual orientation is included in the bio-psychosocial
intake process. CONTRACTOR’s staff shall assume that the population served may not be in
heterosexual relationships. Sensitivity to gender and sexual orientation must be covered in
annual training.
10. Utilize existing community supports, referrals to transgender support groups, etc., when
appropriate.
11. Attend annual Cultural Competence, Compliance, Health Insurance Portability and Accountability
Act (HIPAA), Billing, and Documentation training provided by COUNTY’s DBH.
12. Report its efforts to evaluation cultural and linguistic activities as part of the CONTRACTOR’s
ongoing quality improvement efforts in the monthly activities report. Reported information may
include clients’ complaints and grievances, any resulting actions regarding complaints and
Exhibit A-2
Page 8 of 11
grievances, results from client satisfaction surveys, and utilization and other clinical data that
may reveal health disparities as a result of cultural and linguistic barriers.
C. Regarding direct admissions to the YOUTH CSC from COUNTY’s DBH programs or its contracted providers, the CONTRACTOR agrees to the following:
1. To allow direct admits from COUNTY’s DBH programs or its contracted providers when Youth
CSC has the capacity to accept clients for services.
2. Said direct admits shall not require medical clearance, if client would otherwise meet the
Emergency Medical Services 5150 Destination Policy requirements as mentioned herein below
in Subsection F. However, in the event a referred client is known to possess a contagious
medical condition, said client shall be medically cleared by a local hospital prior to admission to
the Youth CSC operated by CONTRACTOR.
D. Regarding the provision of court testimony related to Youth CSC clients, CONTRACTOR agrees to
the following:
CONTRACTOR’s staff shall provide court testimony relevant to Youth CSC clients, when
required.
E. Regarding placements of Youth in a Psychiatric Health Facility or other inpatient level of care:
CONTRACTOR’s staff shall locate and coordinate transfer for any youth being treated at the
Youth CSC who is in need of further services and placement into a psychiatric health facility
(PHF) or other appropriate acute psychiatric inpatient facility. This includes working
collaboratively with the staffs of Central Star to coordinate the transfer of youth ages 12 to 17 to
their Youth Psychiatric Health Facility. CONTRACTOR acknowledges that transfer of youth may
occur at all hours of the day and agrees to attend promptly to the needs of the youth and will
conduct the transfer as soon as feasibly possible.
F. Regarding the placement of a Youth at another designated facility:
1. CONTRACTOR shall notify COUNTY DBH when a client will remain at the CSC for a period in
excess of 24 hours, while awaiting placement and/or transportation. The COUNTY’s Patients
Rights Advocate will be included in this notification
2. CONTRACTOR shall provide the following services to clients who remain at the CSC for a period
in excess of 24 hours and who are awaiting placement and/or transportation:
a. Three meal periods and three snack times per 24 hours
b. Daily encouragement and support with activities of daily living i.e. showering, washing of
clothes, teeth brushing, hair combing etc.
c. Daily psychiatric evaluation by both the provider and licensed nursing staff to
evaluate/determine the clients most appropriate level of care
d. Daily medication evaluation, administration and education
e. Daily group activities (e.g. 12-Step Meetings, WRAP, Goals Group, etc.)
f. Daily one-on-one peer support provided by designated Peer Advocate
g. Daily activities such as meditation, art, entertainment and outdoor activities provided in the
outside courtyard
h. Daily education in relation to mental health diagnosis, treatments, and community resources
Exhibit A-2
Page 9 of 11
G. Regarding the Emergency Medical Services (EMS) 5150 Destination Policy, CONTRACTOR
agrees to the following:
CONTRACTOR agrees to follow the then-current Emergency Medical Services 5150 Destination
Policy as identified in Exhibit L, attached hereto and incorporated herein. Said policy may be
updated periodically throughout the term of this Agreement; CONTRACTOR must adhere to the
most recent policies designated by the EMS 5150 Destination Policy. References to the
Children’s Crisis Assessment Intervention Resolution (CCAIR) in Exhibit L, reflect services to be
performed at COUNTY’s Youth CSC
H. CONTRACTOR shall participate in the following meetings:
1. CONTRACTOR shall participate in periodic workgroup meetings scheduled by staff from
COUNTY’s DBH Mental Health Contracted Services Unit. The meetings shall be held monthly,
or as needed, to discuss contract requirements, data reporting, outcomes measurement,
training, policies and procedures, and overall program operations.
2. CONTRACTOR’s administrative level agency representative, who is duly authorized to act on
behalf of CONTRACTOR, shall attend regularly scheduled monthly Behavioral Health Board
meetings and its Children’s Services Committee.
3. CONTRACTOR shall attend quarterly or periodic DBH Contractor/Provider Meetings, as
scheduled by staff from COUNTY’s Mental Health Contracted Services Unit, when deemed
necessary by the DBH Director, or designee.
4. CONTRACTOR may also be asked to make presentations in the community about the program
and services that are available
I. Regarding the development of policies and protocols:
CONTRACTOR and COUNTY’s DBH shall collaborate on the development of specific policies
and protocols related to the daily operation of the Youth CSC. Such policies will include, but not
be limited to, the following: placement of youth in psychiatric health facilities or other inpatient
programs either locally or outside the county, facility limitations, and special client populations.
Such policies and protocols shall be mutually agreed upon between CONTRACTOR and
COUNTY’s DBH Director, or designee. Any changes to such policies and protocols shall be
mutually agreed upon between CONTRACTOR and COUNTY’s DBH Director, or designee.
PROGRAM OUTCOMES
The Department of Behavioral Health is dedicated to supporting the wellness of individuals, families and
communities in Fresno County who are affected by, or at the risk of, mental illness and/or substance use
disorders through cultivation of strengths toward promoting recovery in the least restrictive environment.
Five (5) Work Plans will be utilized to support DBH’s mission statement. The work plans were developed as
a concept of a Transformation Plan that would encompass system planning, implementation and oversight
to be reflective of a comprehensive system of care. These work plans are provided below and represent
program goals to be achieved by CONTRACTOR in addition to CONTRACTOR-developed outcomes. DBH
may adjust the outcome measurements needed under this program periodically, so as to best measure the
success of clients and program as determined by the County.
CONTRACTOR will utilize a computerized tracking system with which outcome measures and other
relevant consumer data, such as demographics, will be maintained.
Exhibit A-2
Page 10 of 11
1. Behavioral Health Integrated Access – timeliness between client referral to admission, admission
to treatment, and treatment to discharge; penetration rate; effectiveness of discharge planning as
demonstrated by referral and linkage to other DBH programs, community providers, and other
community resources; and services that provide screening and access to ensure clients are linked to
the services they need, including mental health substance use disorders and physical health
services.
2. Wellness, Recovery, and Resiliency Supports – collaborative approach to treatment strategies to
reduce readmission of consumers with frequent admissions to the facility; effectiveness of services
as demonstrated by the number of consumers who are able to be discharged to the community and
avoid inpatient hospitalization; measurement of recidivism rates, including measuring percentage of
recidivism within 30 days. State the Evidence Based Practices (EBP) that shall be used.
3. Cultural/Community Defined Practices – services or philosophical practices which support the
unique cultural-specific needs of individuals receiving care. Focus on behavioral health practices
which reflect the unique needs of various cultures and communities who reside within Fresno County.
4. Behavioral Health Clinical Care – services where direct therapeutic treatment is provided. Include
the framework of “Levels of Care” where client’s needs, as identified through assessment/screening,
are matched with a complexity and intensity of services meets those needs.
5. Infrastructure Supports – includes all personnel, equipment, programs, and facilities which exist to
support the delivery of care to the clients served. Includes safety, quality improvement and
regulatory compliance functions, along with outcome assessment/program evaluation, training, and
technology.
6. Denial rate for Crisis Stabilization billing will be decreased by 5% within the first six months, based on
previous program denial rates. Rates will be determined by the utilization review performed by
FCMHP.
COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Perform a utilization review, annually at a minimum, (through its FCMHP) of ten percent (10%) of all
admissions to determine that the documentation demonstrates that medical necessity criteria as defined
by the DHCS were met throughout the duration of the crisis stabilization episode. The FCMHP will
maintain discretion regarding possible subsequent utilization review beyond ten percent (10%), as
necessary.
2. Provide oversight of the CONTRACTOR’s Youth CSC program. In addition to contract monitoring of
program(s), oversight includes, but is not limited to, coordination with the DHCS in regard to program
administration and outcomes.
3. Assist the CONTRACTOR in making linkages to the appropriate level of care within the behavioral
health system of care to ensure continuity of care. This will be accomplished through regularly
scheduled meetings as well as formal and informal consultation.
4. Participate in evaluating the progress of the overall program and the efficiency of collaboration with the
CONTRACTOR staff and will be available to the CONTRACTOR for ongoing consultation.
5. Receive and analyze statistical outcome data from CONTRACTOR throughout the term of contract on a
monthly basis. DBH will notify the CONTRACTOR when additional participation is required. The
performance outcome measurement process will not be limited to survey instruments but will also
Exhibit A-2
Page 11 of 11
include, as appropriate, client and staff interviews, chart reviews, and other methods of obtaining
required information.
6. Recognize that cultural competence is a goal toward which professionals, agencies, and systems should
strive. Becoming culturally competent is a developmental process and incorporates at all levels the
importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that
result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to
meet culturally-unique needs. Offering those services in a manner that fails to achieve its intended
result due to cultural and linguistic barriers is not cost effective. To assist the CONTRACTOR’s efforts
towards cultural and linguistic competency, DBH shall provide the following at no cost to
CONTRACTOR:
A. Mandatory cultural competency training including sexual orientation and sensitivity training for
CONTRACTOR personnel, at minimum once per year. COUNTY will provide mandatory training
regarding the special needs of this diverse population and will be included in the cultural
competence training(s). Sexual orientation and sensitivity to gender differences is a basic cultural
competence principle and shall be included in the cultural competency training. Literature suggests
that the mental health needs of lesbian, gay, bisexual, transgender (LGBT) individuals may be at
increased risk for mental disorders and mental health problems due to exposure to societal
stressors such as stigmatization, prejudice and anti-gay violence. Social support may be critical for
this population. Access to care may be limited due to concerns about providers’ sensitivity to
differences in sexual orientation.
B. Assistance to CONTRACTOR in locating appropriate providers who can translate behavioral health
and substance abuse services information into COUNTY’s threshold languages (English, Spanish,
and Hmong). Translation services and costs associated will be the responsibility of the
CONTRACTOR.
Exhibit A-3
Page 1 of 6
ACCESS LINE
Scope of Work
ORGANIZATION: Exodus Recovery, Inc.
ADDRESS: 9808 Venice Boulevard, Suite 700, Culver City, CA 90232
SITE ADDRESS: 4411 E. Kings Canyon Road, Fresno, CA 93702 (Bldg. 319)
SERVICES: Access Line Services
PROJECT DIRECTOR: Luana Murphy, MBA, President/CEO
Phone Number: (559) 453-6271
CONTRACT PERIOD: July 1, 2016 – August 31, 2016 (Ramp Up Period)
September 1, 2016 – June 30, 2019, with two (2) twelve (12) month renewal
options
CONTRACT AMOUNT: Contract Maximum Fiscal Year
$23,678 07/1/2016 through 08/31/2016 (Ramp Up Period)
$242,607 09/01/2016 through 06/30/2017 (Initial Operating Period)
$296,883 FY 2017-18
$307,445 FY 2018-19
$318,384 FY 2019-20
$329,713 FY 2020-21
SCHEDULE OF SERVICES:
CONTRACTOR shall operate a State-mandated toll-free answering service (Access Line) twenty-four (24)
hours per day, seven (7) days per week. The Access Line shall be located at the Kings Canyon Campus at
4411 E. Kings Canyon Road, Fresno, California 93702 (Building 319), a COUNTY-owned building, pursuant to
a separate lease agreement (and any related amendments) between COUNTY and Exodus Foundation, Inc.,
an affiliate of CONTRACTOR.
PROJECT DESCRIPTION:
CONTRACTOR shall provide answering services for the Department of Behavioral Health in accordance with
State and Federal Regulations and utilize the Access Line Database to log all calls. Access line services are
not to be subcontracted out. The 1 (800) 654-3937 access line will be a separate phone line from the Adult
and Youth Crisis Stabilization (CSC) main lines. Calls received on the access line will be monitored and
recorded separately.
1. The Department of Behavioral Health (DBH) is mandated by the State of California to maintain a written
log of all requests for specialty mental health services. The log must include specific information about
each call.1
2. State regulations require that the toll-free, 24/7, Access Line established by DBH also provides
information to Medi-Cal beneficiaries about how to access specialty mental health services, including
information about the grievance and appeals processes and the State’s fair hearing system.2
1 California Code of Regulations (CCR): Title 9, Chapter 11, Section 1810.405(f) & State Department of Health Care Services Program Oversight and
Compliance - Annual Review Protocol for Consolidated Specialty Mental Health Services and Other Funded Services” Section A – Access. 2 California Code of Regulations (CCR): Title 9, Section 1850.205, and Code of Federal Regulations (CFR): Title 42, Part 438, Subpart F.
Exhibit A-3
Page 2 of 6
3. The Access Line database (“Database”) is a web-based application, developed with intuitive, decision-
tree type functionality, and incorporates the requirements stated within the state regulations referenced
above. The Database shall be the mechanism used for collection of caller/client information received by
phone and to provide callers with information as required by the State.
4. Outcomes and expectations for the Access Line may evolve over time, based on changes to State and
Federal Regulations as well as departmental needs and goals. Any changes to Access Line will be
made at the discretion of the Department of Behavioral Health.
5. The Access line shall assess and screen the needs of the caller. The Access line shall triage the call to
meet the needs of each client. Triage shall be provided by staff appropriate to the needs of the client
(nursing staff, clinical staff, etc as needed). Direct linkage with an appropriate plan for each client shall
be provided. When available, scheduling to make client appointments would also be provided.
6. Access line screening shall be provided for mental health and substance use disorder services. The
access line services shall be flexible to meet the growing and changing needs of the Department’s
program and client needs. CONTRACTOR Access Line staffing pattern will be based on call volume.
The Department and CONTRACTOR shall work jointly on future changing needs of the Department, as
needed.
CONTRACTOR’S RESPONSIBILITIES:
CONTRACTOR will utilize the Access Line to triage all calls received and provide linkage, as appropriate.
Calls requiring Emergency Services or Crisis Stabilization Services will be transferred to the appropriate
agency for follow up. Calls not requiring Emergency Services or Crisis Stabilization services will be evaluated
for mental health and/or substance use linkage. Access Line operators will utilize resources including but not
limited to client information within COUNTY’s Avatar Electronic Health Record system, knowledge of
Department of Behavioral Health programs, and community programs to evaluate the caller’s need and form
an action plan with the caller. Callers will be provided with clear instruction regarding next steps. All calls
received, including those transferred to Emergency Services or Crisis Stabilization Services, will be
documented in the Access Line Database, identifying, at minimum, callers Name, Date of Call, and Disposition.
1. Access Line Database: The Database is located at https://www.FCMHPAccessline.com and will be
made available to designated staff. The Database is designed to assist answering service operators
handle calls of the following nature. Each call type requires specific information to be gathered as
indicated by the corresponding call screen, as shown in Exhibit M (“Fresno County Mental Health Plan
24/7 Toll-Free Access Line Intuitive Database for Logging Calls”). All calls will be logged within the
Access Log under the Emergency Calls or Non-Emergency calls listed below in subsection “a” and “b.”
a. Emergency Calls. These calls may require a warm hand-off to emergency medical services
dispatchers. When a call is received and the caller reports self or other to be in crisis or you
cannot be sure of their safety, the following five-step suicide assessment, evaluation, and triage
should be conducted:
1) Identify Risk Factors. Note those that can be modified to reduce risk. Determine if the caller
is alone.
2) Identify Protective Factors. Not those that can be enhanced. If caller is with someone, ask
caller if they are feeling unsafe (harm to self or others, risk of harm by others). If no risk of
harm by others, ask permission to speak to the person to obtain their input and information
about the present situation and history. Ask the caller if they have a therapist and if so, when
is their next appointment.
Exhibit A-3
Page 3 of 6
3) Conduct Suicide Inquiry. Suicidal thoughts, behavior, intent, plan and means, and lethality of
means. Ask about previous suicide attempts and by what means.
4) Determine Risk Level/Intervention. Determine risk. Choose appropriate intervention to
address and reduce risk.
5) Document. Document your assessment of risk, rationale, intervention, and follow up. Inform
treating provider of the call and interventions.
i. If it is determined that the caller is in danger, you may offer to call 9-1-1 for them
to do a safety check and determine if a 5150 hold should be written.
ii. If the caller is with someone who is safe and feels they can transport the caller to
the PHF, recommend that they bring the caller in for an immediate evaluation.
b. Non-Emergency Calls
1) Request No Callback: The caller is requesting only information about mental health
services and does not wish to access services at the time nor receive a call back.
2) Service Requests: The caller is requesting mental health services or calling for
information about services from the Fresno County Mental Health Plan (DBH).
3) Messages: The caller wishes to leave a message for his/her current care provider.
4) Literature Requests: The caller is requesting a Medi-Cal Mental Health Booklet or
Provider List.
5) File Complaint: The caller wishes to file or obtain information about how to file a
complaint, grievance, or appeal with the Fresno County Mental Health Plan.
6) Other Reasons: The caller is calling about something other than what is mentioned
above.
c. User Accounts: Access to the Database for designated CONTRACTOR staff shall be restricted
to inputting call data only.
1) New User Account: CONTRACTOR must submit the following for each designated staff
member requiring access to the Database to set up a user account:
i. First and last name,
ii. Hire date (mm/dd/yyyy), and
iii. Unique identification number (employee ID, clock-in ID, etc.) as assigned by
CONTRACTOR.
2) Account: CONTRACTOR shall notify DBH within 24 hours of any change to user status
or when a user is no longer employed by CONTRACTOR.
d. Password Resets:
1) During Normal Business Hours: A user can request his/her password to be reset by
personally calling DBH’s Information Systems Division Services (ISDS) during normal
business hours. User must verify his/her identity by providing ISDS their full name, hire
date and unique Identification. A new temporary password will be provided upon
satisfactory self-identification.
2) After Normal Business Hours: User will not be able to have his/her password reset after
normal business hours as ISDS will be closed. It is expected that CONTRACTOR staff
assigned to operate the Access Line will set their user accounts during DBH business
hours.
Exhibit A-3
Page 4 of 6
2. Log All Calls:
a. All calls received on the Access Line phone number and by any DBH program utilizing the
phone service shall be logged into the Database, including calls patched to 911 as well as non-
mental health related requests.
b. Information about programs and services requested by callers shall be provided in accordance
to instructions in the Database decision tree.
c. If a user is unable to access the Database temporarily for any reason to log calls (including staff
without an appropriate user account), the user shall document the call by gathering the following
information about the call/caller/client. This information will then be transmitted to DBH via a
facsimile machine to a designated confidential electronic fax number provided by DBH: For
adults, FAX will be transmitted to (559) 600-7615. For children (less than 18 years of age) FAX
will be transmitted to (559) 600-7701.
1) Call Type (identify the type of call: Emergency, No Call Back, Service Request,
Message, Literature Request, File Complaint, or Other)
2) Interpreter Needed? (No/Yes)
3) Language (Specify)
4) Info is for Caller/Client (Identify)
5) First Name
6) Last Name
7) Call Back Phone #
8) Date of Birth (of person seeking services)
9) Estimated Age (Ask for this information only after DOB has been requested and cannot
be provided)
10) Comments (Specify the reason for call: caller wants to file an appeal, hearing voices
and wants to talk to a therapist, connected to 911, etc.)
If the frequency of such occurrences (inability to access the database) reaches a level, as
determined by DBH and regardless of cause that warrants more detailed information to be
logged, CONTRACTOR may be requested to provide up to the level of detail as is collected by
the Database. It is the responsibility of CONTRACTOR to notify DBH, ISDS staff, or designated
staff if the Database Access Log is not accessible.
3. Language Interpreter Services: CONTRACTOR shall utilize the account set up through Fresno
County’s contract with Language Line Services to provide interpreter services to callers when
necessary or appropriate. A Language Line Quick Reference Guide (Exhibit N) is embedded in the
Database as part of the decision tree to assist operators with accessing this service.
a. Instances considered necessary or appropriate include, but are not limited to, when such
services is being requested or is accepted by the caller; the operator does not speak the caller’s
language; or the operator feels such services are necessary for effective communication with
the caller.
b. All costs related to the use of Language Line services through this account will be paid for by
Fresno County directly to Language Line Services and shall not be a part of this Agreement.
c. DBH is not responsible for costs related to interpreter services provided to callers by any other
party or agency.
Exhibit A-3
Page 5 of 6
4. TDD/Relay Service: CONTRACTOR shall utilize either a Telecommunication Device for the Deaf
(TDD) service or Telecommunication Relay Services (TRS) when handling calls from clients who are
Deaf, Hard of Hearing, Speech-Disabled or Deaf and Blind. CONTRACTOR may utilize the TRS if
unable to secure TDD equipment, to communicate with a caller whom the operator determines may be
deaf, hearing-impaired or speech-disabled.
5. Evaluation of Protocols: CONTRACTOR and DBH will collaborate in the ongoing evaluation of
protocols for the design and flow of Access Line services. Changes to the Access Line will be mutually
agreed upon by CONTRACTOR and DBH and be in accordance with mandates by the State of
California.
PERFORMANCE MEASUREMENTS AND MONITORING
As mandated by the State, CONTRACTOR shall meet all performance goals on a monthly basis as detailed
below in Table A. The Database is designed to enable telephone operators to appropriately handle calls
received on the Access Line and to collect the required information within the Access Log.
1. Performance Measures:
Table A: Performance Measures
# Performance Measure Goal
1. Call was logged in Access Line Database 100%
2. Operator asked if the caller’s/client’s situation is an emergency 100%
3. Operator asked for caller’s/client’s name 100%
4. Operator logged caller’s/client’s name accurately in Database. Calls where
caller does not provide a name will be recorded as such, “No Name Provided.”
100%
5. Operator asked for caller’s/client’s call back phone number 100%
6. Operator logged caller’s/client’s call back phone number accurately in Database 100%
7. Operator asked for the reason for call 100%
8. Operator logged the reason for call accurately in Database 100%
9. Operator utilized AT&T Language Line Service when applicable
a. Caller requests/accepts interpreter services
b. Operator does not speak the caller’s language
c. Operator feels interpreter services are necessary
100%
10. Operator provided appropriate linkages to mental health services
a. To the adult services program(s) as indicated in the Access Line
Database
b. To the children’s services program(s) as indicated in the Access Line
Database
100%
11. Operator provided information on the grievances/appeals/State fair hearing
process
100%
2. Performance Monitoring: DBH will conduct test calls of the Access Line on a monthly basis to monitor
the performance measures described in Table A.
a. Test calls may be made in English and/or non-English languages as deemed appropriated by
DBH.
Exhibit A-3
Page 6 of 6
b. The number of test calls performed by DBH to the Access Line each month shall match the
number of test calls conducted by the State during their review of the Access Line as stated in
the most recent version of the State Medi-Cal Protocol. For Fiscal Year 2016-17, the number of
test calls will be, at minimum, seven (7) per month.
c. Test Call Outcomes Feedback: DBH will provide feedback on test call outcomes to
CONTRACTOR designated staff overseeing the Access Line as follows:
1) The results of individual test calls shall be provided to CONTRACTOR designated staff
within 24 hours or as soon as possible after the call is performed and the “Access Line
Test Call Feedback Form” (Exhibit O) is completed.
2) A monthly Test Call Outcomes Summary Report of all test calls performed during the
preceding month shall be provided to CONTRACTOR within 14 days after month end.
3. Corrective Action Plan: An “Access Line Statement of Deficiencies and Plan of Correction” (Exhibit P)
shall accompany the monthly Test Call Outcomes Summary Report if any goal was unmet (outcome
falls below 100%) or issues related to test calls were not resolved satisfactorily.
a. The “Category” and “Summary Statement of Deficiencies” will be completed by DBH based
upon findings from the monthly report.
b. CONTRACTOR shall complete the “Provider’s Plan of Correction” and “Completion Date”
sections, sign and date the form and return it to the department within 14 calendar days from
the date of receipt.
c. The completed form shall be returned to the designated DBH staff, in compliance with HIPAA
regulations regarding safeguarding client information when applicable.
E-MAILING PROTECTED HEALTH INFORMATION (PHI)
Any e-mail communication with/to DBH staff containing client Protected Health Information (PHI) shall be done
so in compliance with HIPAA regulations on PHI as follows:
1. Include the Confidentiality Statement below at the beginning of all e-mails containing PHI and at the
beginning of each e-mail in a string of emails that contain PHI.
2. Confidentiality Statement:
Confidentiality Statement: This e-mail message, including any attachments, is for the
sole use of the intended recipient(s) and may contain confidential and privileged
information. Any unauthorized review, use, disclosure or distribution is prohibited. If you
are not the intended recipient, please contact the sender without using reply e-mail and
destroy all copies of the original message.
3. Examples of PHI: Client Name, Address, Phone Number, Date of Birth, Social Security Number
4. Do not include the client’s name in the “Subject” line of the e-mail.
5. All phone calls and messages emailed to DBH staff containing PHI shall be sent as an encrypted
attachment. A standard password will be provided by DBH. Do not list the password within the body of
the e-mail.
Note: when appropriate, DBH ISDS staff is available to provide technical support.
Exhibit B-1
Page: 1 of 7
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25 $35,750 $35,750
0002 0.75 $134,536 $1,359 $135,895
0003 16.80 $1,178,174 $1,178,174
0004 2.50 $143,714 $143,714
0005 12.60 $459,480 $459,480
0006 1.00 $32,500 $32,500
0007 1.00 $37,596 $37,596
0008 1.00 $68,455 $68,455
0009 1.00 $31,200 $31,200
0010 2.00 $41,600 $41,600
0011 0.50 $24,960 $24,960
0012 0.20 $13,728 $13,728
SALARY TOTAL 39.60 $420,325 $1,782,727 $2,203,052
PAYROLL TAXES:
0030 $3,909 $16,579 $20,488
0031 $33,122 $140,479 $173,601
0032 $7,763 $32,462 $40,225
PAYROLL TAX TOTAL $44,794 $189,520 $234,314
EMPLOYEE BENEFITS:
0040 $16,813 $71,309 $88,122
0041 $27,321 $115,877 $143,198
0042 $54,642 $231,755 $286,397
EMPLOYEE BENEFITS TOTAL $98,776 $418,941 $517,717
SALARY & BENEFITS GRAND TOTAL $2,955,083
FACILITIES/EQUIPMENT EXPENSES:
1010 $0
1011 $33,503
1012 $73,796
1013 $67,131
1014 $26,041
1015 $901,085
1016 $0
1017 $8,520
1018 $0
FACILITY/EQUIPMENT TOTAL $1,110,076
OPERATING EXPENSES:
1060 $30,511
1061 $0
1062 $710
1063 $12,158
1064 $1,065
1065 $1,775
1066 $63,790
Other - Business Taxes/Licenses-Permits
Other - One Time Start-Up Costs
Answering Service
Printing/Reproduction
Publications
Legal Notices/Advertising
Telephone
SUI
Retirement
Workers Compensation
Rent/Lease Building
Rent/Lease Equipment
Utilities
Driver
Peer Counselor
Intake Coordinator
Billing Supervisor
OASDI
FICA/MEDICARE
VP Northern Region
Program Director (RN)
Program Nurses
Social Service Coordinators
Mental Health Worker
Data Specialist
Benefits/PAP Coordinator
Program Assistant
Health Insurance (medical vision, life, dental)
Postage
Janitorial
Maintenance (facility)
Security Personnel
Maintenance (durable medical equipment)
Office Supplies & Equipment
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2016 to June 30, 2017
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Exhibit B-1
Page: 2 of 7
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2016 to June 30, 2017
1067 $0
1068 $0
1069 $0
1070 $32,577
1071 $3,880
1072 $2,982
1073 Staff Travel (Out of Office)$1,065
1074 $40,578
1075 $0
1076 $1,149,267
1077 $25,229
OPERATING EXPENSES TOTAL $1,365,587
FINANCIAL SERVICES EXPENSES:
1080 $26,775
1081 $4,500
1082 $20,600
1083 $851,447
1084 $0
1085 $0
FINANCIAL SERVICES TOTAL $903,322
SPECIAL EXPENSES (Consultant/Etc.):
1087 $22,602
1088 $1,420
1089 $46,860
1090 $79,062
1091 $37,420
1092 $4,333
1093 $0
1094 $0
1095 $2,000
1096 $0
1097 $0
1098 $0
SPECIAL EXPENSES TOTAL $193,697
FIXED ASSETS:
2000 $0
2001 $0
2002 $0
2003 $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $6,527,765
Computers & Software
Furniture & Fixtures
Other - (identify)
Other - (identify)
Nutritionist Services
X-ray and EKG Services
Pharmaceutical Consultants
Medical Services
Access Line
Other - (identify)
Consultant (network & data management)
Translation Services
Medication Supports (Pharmaceuticals)
Food Service
Laundry Service
Medical Waste Disposal
Accounting/Bookkeeping
External Audit
Liability Insurance
Other-Administrative Overhead
Other - (identify)
Other - (identify)
Household Supplies
Food
Program Supplies - Therapeutic
Lodging
Other - Personnel Related Exp/Contracted PR Exp/Parking
Other - Flex Funds
Program Supplies - Medical
Staff Mileage/Vehicle Maintenance
Staff Training/Registration
Transportation of Clients
Exhibit B-1
Page: 3 of 7
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2016 to June 30, 2017
DIRECT SERVICE REVENUE:
Vol/Units of
Service Rate $ Amt.
3000 0 $0.00 $0
3100 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Crisis Stabilization - Urgent Care 69,048 $94.54 $6,527,765
3500 Other - (Identify)0 $0.00 $0
3600 Other - (Identify)0 $0.00 $0
3700 Other - (Identify)0 $0.00 $0
DIRECT SERVICE REVENUE TOTAL 69,048 $6,527,765
$3,263,882
$94.54
FUNDING STREAM REIMBURSEMENT Population Served Percentage
4000 7 $456,944
4100 15 $979,165
4200 39 $2,545,828
4300 39 $2,545,828
OTHER REVENUE/SOCIAL SERVICES TOTAL $6,527,765
TOTAL PROGRAM REVENUE $6,527,765
Realignment
Mental Health Services (Individual/Family/Group Therapy)
Case Management
Uninsured
Medi-Cal FFP
Private Insurance
Medi-cal Revenue
Cost Per Unit
Exhibit B-1
Page: 4 of 7
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25 $36,823 $36,823
0002 0.75 $138,533 $1,399 $139,932
0003 16.80 $1,213,519 $1,213,519
0004 2.50 $148,025 $148,025
0005 12.60 $473,264 $473,264
0006 1.00 $33,475 $33,475
0007 1.00 $38,724 $38,724
0008 1.00 $70,509 $70,509
0009 1.00 $32,136 $32,136
0010 2.00 $42,848 $42,848
0011 0.50 $25,709 $25,709
0012 0.20 $14,140 $14,140
SALARY TOTAL 39.60 $432,897 $1,836,207 $2,269,104
PAYROLL TAXES:
0030 $4,026 $17,077 $21,103
0031 $34,112 $144,693 $178,805
0032 $8,011 $33,497 $41,508
PAYROLL TAX TOTAL $46,149 $195,267 $241,416
EMPLOYEE BENEFITS:
0040 $17,316 $73,448 $90,764
0041 $28,138 $119,354 $147,492
0042 $56,276 $238,707 $294,983
EMPLOYEE BENEFITS TOTAL $101,730 $431,509 $533,239
SALARY & BENEFITS GRAND TOTAL $3,043,759
FACILITIES/EQUIPMENT EXPENSES:
1010 $0
1011 $34,508
1012 $76,010
1013 $69,145
1014 $26,822
1015 $928,118
1016 $0
1017 $8,776
1018 $0
FACILITY/EQUIPMENT TOTAL $1,143,379
OPERATING EXPENSES:
1060 $31,426
1061 $0
1062 $731
1063 $12,523
1064 $1,097
1065 $1,828
1066 $65,704
Printing/Reproduction
Publications
Legal Notices/Advertising
Office Supplies & Equipment
Maintenance (durable medical equipment)
Other - Business Taxes/Licenses-Permits
Other - One Time Start-Up Costs
Telephone
Answering Service
Postage
Rent/Lease Building
Rent/Lease Equipment
Utilities
Janitorial
Maintenance (facility)
Security Personnel
OASDI
FICA/MEDICARE
SUI
Retirement
Workers Compensation
Health Insurance (medical vision, life, dental)
Benefits/PAP Coordinator
Program Assistant
Driver
Peer Counselor
Intake Coordinator
Billing Supervisor
VP Northern Region
Program Director (RN)
Program Nurses
Social Service Coordinators
Mental Health Worker
Data Specialist
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Exhibit B-1
Page: 5 of 7
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
1067 $0
1068 $0
1069 $0
1070 $33,554
1071 $3,996
1072 $3,071
1073 Staff Travel (Out of Office)$1,097
1074 $41,795
1075 $0
1076 $1,183,743
1077 $25,986
OPERATING EXPENSES TOTAL $1,406,551
FINANCIAL SERVICES EXPENSES:
1080 $27,578
1081 $4,635
1082 $21,218
1083 $876,994
1084 $0
1085 $0
FINANCIAL SERVICES TOTAL $930,425
SPECIAL EXPENSES (Consultant/Etc.):
1087 $23,280
1088 $1,463
1089 $48,266
1090 $81,434
1091 $38,543
1092 $4,463
1093 $0
1094 $0
1095 $2,060
1096 $0
1097 $0
1098 $0
SPECIAL EXPENSES TOTAL $199,509
FIXED ASSETS:
2000 $0
2001 $0
2002 $0
2003 $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $6,723,623
Access Line
Other - (identify)
Computers & Software
Furniture & Fixtures
Other - (identify)
Other - (identify)
Laundry Service
Medical Waste Disposal
Nutritionist Services
X-ray and EKG Services
Pharmaceutical Consultants
Medical Services
Other - (identify)
Other - (identify)
Consultant (network & data management)
Translation Services
Medication Supports (Pharmaceuticals)
Food Service
Other - Personnel Related Exp/Contracted PR Exp/Parking
Other - Flex Funds
Accounting/Bookkeeping
External Audit
Liability Insurance
Other-Administrative Overhead
Program Supplies - Therapeutic
Program Supplies - Medical
Transportation of Clients
Staff Mileage/Vehicle Maintenance
Staff Training/Registration
Lodging
Household Supplies
Food
Exhibit B-1
Page: 6 of 7
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
DIRECT SERVICE REVENUE:
Vol/Units of
Service Rate $ Amt.
3000 0 $0.00 $0
3100 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Crisis Stabilization - Urgent Care 71,119 $94.54 $6,723,624
3500 Other - (Identify)0 $0.00 $0
3600 Other - (Identify)0 $0.00 $0
3700 Other - (Identify)0 $0.00 $0
DIRECT SERVICE REVENUE TOTAL 71,119 6,723,624
3,361,812
$94.54
FUNDING STREAM REIMBURSEMENT Population Served Percentage
4000 7 $470,654
4100 15 $1,008,544
4200 39 $2,622,213
4300 39 $2,622,213
OTHER REVENUE/SOCIAL SERVICES TOTAL $6,723,624
TOTAL PROGRAM REVENUE $6,723,624
Private Insurance
Uninsured
Medi-Cal FFP
Realignment
Mental Health Services (Individual/Family/Group Therapy)
Case Management
Medi-cal Revenue
Cost Per Unit
Exhibit B-1
Page: 7 of 7
Fiscal Year Total Program
Expenses
2018-2019 $6,925,332
2019-2020 $7,133,092
2020-2021 $7,347,085
Adult Crisis Stabilization Center
Exodus Recovery, Inc.
Optional Years Budget
Exhibit B-2
Page: 1 of 7
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25 $35,750 $35,750
0002 0.00 $0
0003 8.40 $575,266 $575,266
0004 1.40 $94,108 $94,108
0005 8.40 $284,357 $284,357
0006 0.00 $0
0007 0.00 $0
0008 0.00 $0
0009 0.00 $0
0010 0.00 $0
0011 0.50 $24,960 $24,960
0012 0.20 $14,414 $14,414
SALARY TOTAL 19.15 $75,124 $953,731 $1,028,855
PAYROLL TAXES:
0030 $699 $8,870 $9,569
0031 $5,920 $75,154 $81,074
0032 $1,411 $17,919 $19,330
PAYROLL TAX TOTAL $8,030 $101,943 $109,973
EMPLOYEE BENEFITS:
0040 $3,005 $38,149 $41,154
0041 $4,883 $61,992 $66,875
0042 $9,766 $123,985 $133,751
EMPLOYEE BENEFITS TOTAL $17,654 $224,126 $241,780
SALARY & BENEFITS GRAND TOTAL $1,380,608
FACILITIES/EQUIPMENT EXPENSES:
1010 $0
1011 $16,184
1012 $30,142
1013 $27,420
1014 $10,637
1015 $388,471
1016 $0
1017 $3,480
1018 $0
FACILITY/EQUIPMENT TOTAL $476,334
OPERATING EXPENSES:
1060 $19,749
1061 $0
1062 $290
1063 $4,966
1064 $435
1065 $725
1066 $30,598
Printing/Reproduction
Publications
Legal Notices/Advertising
Office Supplies & Equipment
Maintenance (durable medical equipment)
Other - Business Taxes/Licenses-Permits
Other - One Time Start-Up Costs
Telephone
Answering Service
Postage
Rent/Lease Building
Rent/Lease Equipment
Utilities
Janitorial
Maintenance (facility)
Security Personnel
OASDI
FICA/MEDICARE
SUI
Retirement
Workers Compensation
Health Insurance (medical vision, life, dental)
Benefits/PAP Coordinator
Program Assistant
Driver
Peer Counselor
Intake Coordinator
Billing Supervisor
VP Northern Region
Program Director (RN)
Program Nurses
Social Service Coordinators
Mental Health Worker
Data Specialist
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2016 to June 30, 2017
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Exhibit B-2
Page: 2 of 7
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2016 to June 30, 2017
1067 $0
1068 $0
1069 $0
1070 $13,306
1071 $1,585
1072 $1,218
1073 Staff Travel (Out of Office)$435
1074 $14,896
1075 $0
1076 $265,935
1077 $10,305
OPERATING EXPENSES TOTAL $364,443
FINANCIAL SERVICES EXPENSES:
1080 $2,975
1081 $500
1082 $8,414
1083 $344,400
1084 $0
1085 $0
FINANCIAL SERVICES TOTAL $356,289
SPECIAL EXPENSES (Consultant/Etc.):
1087 $5,651
1088 $580
1089 $19,140
1090 $24,984
1091 $11,603
1092 $765
1093 $0
1094 $0
1095 $0
1096 $0
1097 $0
1098 $0
SPECIAL EXPENSES TOTAL $62,723
FIXED ASSETS:
2000 $0
2001 $0
2002 $0
2003 $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $2,640,397
Access Line
Other - (identify)
Computers & Software
Furniture & Fixtures
Other - (identify)
Other - (identify)
Laundry Service
Medical Waste Disposal
Nutritionist Services
X-ray and EKG Services
Pharmaceutical Consultants
Medical Services
Other - (identify)
Other - (identify)
Consultant (network & data management)
Translation Services
Medication Supports (Pharmaceuticals)
Food Service
Other - Personnel Related Exp/Contracted PR Exp/Parking
Other - Flex Funds
Accounting/Bookkeeping
External Audit
Liability Insurance
Other-Administrative Overhead
Program Supplies - Therapeutic
Program Supplies - Medical
Transportation of Clients
Staff Mileage/Vehicle Maintenance
Staff Training/Registration
Lodging
Household Supplies
Food
Exhibit B-2
Page: 3 of 7
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2016 to June 30, 2017
DIRECT SERVICE REVENUE:
Vol/Units of
Service Rate $ Amt.
3000 0 $0.00 $0
3100 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Crisis Stabilization - Urgent Care 27,929 $94.54 $2,640,397
3500 Other - (Identify)0 $0.00 $0
3600 Other - (Identify)0 $0.00 $0
3700 Other - (Identify)0 $0.00 $0
DIRECT SERVICE REVENUE TOTAL 27,929 $2,640,397
$1,320,199
$94.54
FUNDING STREAM REIMBURSEMENT Population Served Percentage
4000 7 $184,828
4100 15 $396,060
4200 39 $1,029,755
4300 39 $1,029,755
OTHER REVENUE/SOCIAL SERVICES TOTAL $2,640,397
TOTAL PROGRAM REVENUE $2,640,397
Private Insurance
Uninsured
Medi-Cal FFP
Realignment
Mental Health Services (Individual/Family/Group Therapy)
Case Management
Medi-cal Revenue
Cost Per Unit
Exhibit B-2
Page: 4 of 7
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25 $36,823 $36,823
0002 0.00 $0
0003 8.40 $592,524 $592,524
0004 1.40 $96,932 $96,932
0005 8.40 $292,888 $292,888
0006 0.00 $0
0007 0.00 $0
0008 0.00 $0
0009 0.00 $0
0010 0.00 $0
0011 0.50 $25,709 $25,709
0012 0.20 $14,847 $14,847
SALARY TOTAL 19.15 $77,379 $982,344 $1,059,723
PAYROLL TAXES:
0030 $720 $9,136 $9,856
0031 $6,097 $77,409 $83,506
0032 $1,456 $18,491 $19,947
PAYROLL TAX TOTAL $8,273 $105,036 $113,309
EMPLOYEE BENEFITS:
0040 $3,095 $39,294 $42,389
0041 $5,030 $63,852 $68,882
0042 $10,059 $127,705 $137,764
EMPLOYEE BENEFITS TOTAL $18,184 $230,851 $249,035
SALARY & BENEFITS GRAND TOTAL $1,422,067
FACILITIES/EQUIPMENT EXPENSES:
1010 $0
1011 $16,670
1012 $31,046
1013 $28,243
1014 $10,956
1015 $400,125
1016 $0
1017 $3,584
1018 $0
FACILITY/EQUIPMENT TOTAL $490,624
OPERATING EXPENSES:
1060 $20,341
1061 $0
1062 $299
1063 $5,115
1064 $448
1065 $747
1066 $31,516
Printing/Reproduction
Publications
Legal Notices/Advertising
Office Supplies & Equipment
Maintenance (durable medical equipment)
Other - Business Taxes/Licenses-Permits
Other - One Time Start-Up Costs
Telephone
Answering Service
Postage
Rent/Lease Building
Rent/Lease Equipment
Utilities
Janitorial
Maintenance (facility)
Security Personnel
OASDI
FICA/MEDICARE
SUI
Retirement
Workers Compensation
Health Insurance (medical vision, life, dental)
Benefits/PAP Coordinator
Program Assistant
Driver
Peer Counselor
Intake Coordinator
Billing Supervisor
VP Northern Region
Program Director (RN)
Program Nurses
Social Service Coordinators
Mental Health Worker
Data Specialist
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Exhibit B-2
Page: 5 of 7
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
1067 $0
1068 $0
1069 $0
1070 $13,705
1071 $1,633
1072 $1,255
1073 Staff Travel (Out of Office)$448
1074 $15,343
1075 $0
1076 $273,913
1077 $10,614
OPERATING EXPENSES TOTAL $375,377
FINANCIAL SERVICES EXPENSES:
1080 $3,064
1081 $515
1082 $8,667
1083 $354,738
1084 $0
1085 $0
FINANCIAL SERVICES TOTAL $366,984
SPECIAL EXPENSES (Consultant/Etc.):
1087 $5,821
1088 $597
1089 $19,714
1090 $25,734
1091 $11,951
1092 $788
1093 $0
1094 $0
1095 $0
1096 $0
1097 $0
1098 $0
SPECIAL EXPENSES TOTAL $64,605
FIXED ASSETS:
2000 $0
2001 $0
2002 $0
2003 $0
FIXED ASSETS TOTAL $0
TOTAL PROGRAM EXPENSES $2,719,657
Access Line
Other - (identify)
Computers & Software
Furniture & Fixtures
Other - (identify)
Other - (identify)
Laundry Service
Medical Waste Disposal
Nutritionist Services
X-ray and EKG Services
Pharmaceutical Consultants
Medical Services
Other - (identify)
Other - (identify)
Consultant (network & data management)
Translation Services
Medication Supports (Pharmaceuticals)
Food Service
Other - Personnel Related Exp/Contracted PR Exp/Parking
Other - Flex Funds
Accounting/Bookkeeping
External Audit
Liability Insurance
Other-Administrative Overhead
Program Supplies - Therapeutic
Program Supplies - Medical
Transportation of Clients
Staff Mileage/Vehicle Maintenance
Staff Training/Registration
Lodging
Household Supplies
Food
Exhibit B-2
Page: 6 of 7
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
DIRECT SERVICE REVENUE:
Vol/Units of
Service Rate $ Amt.
3000 0 $0.00 $0
3100 0 $0.00 $0
3200 Crisis Services 0 $0.00 $0
3300 Medication Support 0 $0.00 $0
3400 Crisis Stabilization - Urgent Care 28,767 $94.54 $2,719,656
3500 Other - (Identify)0 $0.00 $0
3600 Other - (Identify)0 $0.00 $0
3700 Other - (Identify)0 $0.00 $0
DIRECT SERVICE REVENUE TOTAL 28,767 $2,719,656
$1,359,828
$94.54
FUNDING STREAM REIMBURSEMENT Population Served Percentage
4000 7 $190,376
4100 15 $407,948
4200 39 $1,060,666
4300 39 $1,060,666
OTHER REVENUE/SOCIAL SERVICES TOTAL $2,719,656
TOTAL PROGRAM REVENUE $2,719,656
Private Insurance
Uninsured
Medi-Cal FFP
Realignment
Mental Health Services (Individual/Family/Group Therapy)
Case Management
Medi-cal Revenue
Cost Per Unit
Exhibit B-2
Page: 7 of 7
Fiscal Year Total Program
Expenses
2018-2019 $2,801,247
2019-2020 $2,885,284
2020-2021 $2,971,842
Youth Crisis Stabilization Center
Exodus Recovery, Inc.
Optional Years Budget
Exhibit B-3
Page: 1 of 4
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25
0002 Licensed Staff (Mon - Fri 16 hours per day)2.00
0003 0.50
SALARY TOTAL 2.75 $0
PAYROLL TAXES:
0030
0031
0032
PAYROLL TAX TOTAL $0
EMPLOYEE BENEFITS:
0040
0041
0042
EMPLOYEE BENEFITS TOTAL $0
SALARY & BENEFITS GRAND TOTAL $0
OPERATING EXPENSES:
1060 $0
1066 $0
1074 $19,529
1075 $0
1076 Other - One-Time Costs (TDD Equipment/Phone Headsets)$1,060
1077 $0
OPERATING EXPENSES TOTAL $20,589
FINANCIAL SERVICES EXPENSES:
1082 $0
1083 $3,089
FINANCIAL SERVICES TOTAL $3,089
TOTAL PROGRAM EXPENSES $23,678
Access Line
Exodus Recovery, Inc.
July 1, 2016 to August 31, 2016 (Ramp Up)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Supervisor (10 hrs weekly CSC Program Director)*
Licensed Staff (CSC Afterhours/Weekends/Holidays)
OASDI
FICA/MEDICARE
SUI
Retirement
Other -- License Business Tax
Liability Insurance
Administrative Overhead
Workers Compensation
Medical/Dental/Vision Plan
Telephone
Office Supplies
Staff Orientation (One-Time Cost, 1 month)
Staff Training - Ongoing
Exhibit B-3
Page: 2 of 4
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25 $28,592
0002 Licensed Staff (Mon - Fri 16 hours per day)2.00 $110,933
0003 0.50 $8,367
SALARY TOTAL 2.75 $147,892
PAYROLL TAXES:
0030 $1,375
0031 $11,654
0032 $2,776
PAYROLL TAX TOTAL $15,805
EMPLOYEE BENEFITS:
0040 $5,916
0041 $9,554
0042 $16,120
EMPLOYEE BENEFITS TOTAL $31,590
SALARY & BENEFITS GRAND TOTAL $195,287
OPERATING EXPENSES:
1060 $6,000
1066 $2,400
1075 $5,526
1076 $750
1077
OPERATING EXPENSES TOTAL $14,676
FINANCIAL SERVICES EXPENSES:
1082 $1,000
1083 $31,644
FINANCIAL SERVICES TOTAL $32,644
TOTAL PROGRAM EXPENSES $242,607
Access Line
Exodus Recovery, Inc.
September 1, 2016 to June 30, 2016 (Initial Operating Period)
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Supervisor (10 hrs weekly CSC Program Director)*
Licensed Staff (CSC Afterhours/Weekends/Holidays)
OASDI
FICA/MEDICARE
SUI
Retirement
Other - One-Time Costs (TDD Equipment/Phone Hea
Other -- License Business Tax
Liability Insurance
Administrative Overhead (15%)
Workers Compensation
Medical/Dental/Vision Plan
Telephone
Office Supplies
Staff Training - Ongoing
Exhibit B-3
Page: 3 of 4
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 0.25 $35,340
0002 Licensed Staff (Mon - Fri 16 hours per day)2.00 $137,113
0003 0.50 $10,342
SALARY TOTAL 2.75 $182,795
PAYROLL TAXES:
0030 $1,572
0031 $14,843
0032 $2,861
PAYROLL TAX TOTAL $19,276
EMPLOYEE BENEFITS:
0040 $7,312
0041 $12,156
0042 $20,473
EMPLOYEE BENEFITS TOTAL $39,941
SALARY & BENEFITS GRAND TOTAL $242,012
OPERATING EXPENSES:
1060 $6,180
1066 $2,472
1075 $5,692
1077 $773
OPERATING EXPENSES TOTAL $15,117
FINANCIAL SERVICES EXPENSES:
1082 $1,030
1083 $38,724
FINANCIAL SERVICES TOTAL $39,754
TOTAL PROGRAM EXPENSES $296,883
Access Line
Exodus Recovery, Inc.
July 1, 2017 to June 30, 2018
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Supervisor (10 hrs weekly CSC Program Director)*
Licensed Staff (CSC Afterhours/Weekends/Holidays)
OASDI
FICA/MEDICARE
SUI
Retirement
Other -- License Business Tax
Liability Insurance
Administrative Overhead (15%)
Workers Compensation
Medical/Dental/Vision Plan
Telephone
Office Supplies
Staff Training - Ongoing
Exhibit B-3
Page: 4 of 4
Fiscal Year Total Program
Expenses
2018-2019 $307,445
2019-2020 $318,384
2020-2021 $329,713
Access Line
Exodus Recovery, Inc.
Optional Years Budget
Exhibit C
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit C
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit C
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
Exhibit D
Page 1 of 3
0374 d dbh
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified and
updated as appropriate.
• Presenting problems and relevant conditions affecting the client’s physical health and mental
health status will be documented, for example: living situation, daily activities, and social
support.
• Documentation will describe client’s strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently documented
and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates, providers,
therapeutic interventions and responses, sources of clinical data, relevant family information and
relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as well as
illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A five axis diagnosis from the most current DSM, or a diagnosis from the most current ICD,
will be documented, consistent with the presenting problems, history mental status evaluation
and/or other assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in the
client’s condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B. Client Plans
1. Client plans will:
Exhibit D
Page 2 of 3
0374 d dbh
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
* the person providing the service(s), or
* a person representing a team or program providing services, or
* a person representing the MHP providing services
* when the client plan is used to establish that the services are provided under the direction of an
approved category of staff, and if the below staff are not the approved category,
* a physician
* a licensed/ “waivered” psychologist
* a licensed/ “associate” social worker
* a licensed/ registered/marriage and family therapist or
* a registered nurse
• In addition,
* client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client’s participation
in and agreement with the plan. Examples of the documentation include, but are not limited to,
reference to the client’s participation and agreement in the body of the plan, client signature on
the plan, or a description of the client’s participation and agreement in progress notes.
* client signature on the plan will be used as the means by which the CONTRACTOR(S)
documents the participation of the client
* when the client’s signature is required on the client plan and the client refuses or is unavailable
for signature, the client plan will include a written explanation of the refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the individual
elements of the client plan described in item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client’s progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• All entries in the client record will include the signature of the person providing the service (or
electronic equivalent); the person’s professional degree, licensure or job title; and the relevant
identification number, if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care, or as appropriate, a discharge summary
Exhibit D
Page 3 of 3
0374 d dbh
2. Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
Mental Health Services
Medication Support Services
Crisis Intervention
Exhibit E
Page 1 of 2
0374 f dbh
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit E
Page 2 of 2
0374 f dbh
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights
EXHIBIT F
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
EXHIBIT F
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation,
the provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Health Care
Service’s day treatment requirements. The COUNTY shall review the provider’s written
program description for compliance with the State Department of Health Care Service’s
day treatment requirements.
12. The COUNTY may accept the host county’s site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example:
conversion from a non-profit status).
• The provider adds day treatment or medication support services when medications
shall be administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some
physical plant changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for
clients, staff or members of the community.
Exhibit 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
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 H
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List 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 I
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit I
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit J
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit J
Page 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) Have not within a three-year period preceding this application/proposal had one
or more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit K
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit K
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5) Authorized Signature
Signature: Date:
CENTRAL CALIFORNIA
EMERGENCY MEDICAL SERVICES
A Division of the Fresno County Department of Public Health
Manual
Emergency Medical Services
Administrative Policies and Procedures
Policy
Number 547
Page 1 of 10
Subject Patient Destination
References Title 13, Section 1106 of the California Code of Regulations
Title 22, Division 9, Chapter 7 of the California Code of Regulations
Effective:
04/18/83
I. POLICY
Patients of the Prehospital EMS System shall be transported to an appropriately staffed and equipped hospital.
II.MEDICAL PATIENT DESTINATION
A. Medical Patients shall be transported to the appropriate destination in accordance with the following chart:
Fresno County Kings County Madera County Tulare County
Medical – Adult
Non-emergent Patient’s Choice Patient’s Choice Patient’s Choice Patient’s Choice
Life-threatening Closest Appropriate Closest Appropriate Closest Appropriate Closest Appropriate
Acute current of injury
(acute MI)
Regional Medical
Center or St. Agnes
Medical Center
(Quickest travel time)
Kaweah Delta Medical
Center or Regional
Medical Center
(Quickest travel time)
Regional Medical
Center or St. Agnes
Medical Center
(Quickest travel time)
Kaweah Delta Medical
Center or Regional
Medical Center
(Quickest travel time)
Medical – Pediatric (14 years or younger)
Stable Patient/Family Choice Patient/Family Choice Patient/Family Choice Patient/Family Choice
Unstable RMC or Children’s ***
(Quickest travel time)
RMC or Children’s ***
(Quickest travel time)
RMC or Children’s ***
(Quickest travel time)
Kaweah Delta Medical
Center or
Sierra View District
Hospital ***
(Quickest travel time)
5150 patients
5150 - Adult CSC or Patient’s Choice
within Fresno County
Patient’s Choice within
Kings County
Patient’s Choice within
Madera County
Patient’s Choice within
Tulare County
5150 – Children (<18 yrs)
CCAIR or
Patient/Family Choice
(See criteria below)
Patient/Family Choice
within Kings County
Patient/Family Choice
within Madera County
Patient/Family Choice
within Tulare County
Kaiser (within Kaiser
Facility)
Kaiser designated
facility N/A N/A N/A
Veteran’s
Administration
Veteran’s
Administration N/A N/A N/A
*** If transport time is greater than 60 minutes, base hospital contact shall be made to determine appropriate destination.
Approved By
Signatures on File at EMS Agency
EMS Division Manager
Revision
01/01/2015
Signatures on File at EMS Agency
EMS Medical Director
Exhibit L
Page 1 of 10
Page 2 of 10
Subject:
Patient Destination
Policy
Number: 547
B.Medical Patient Destination – Considerations
1.In a non-emergent situation (as determined by the EMT or Paramedic at the scene and/or the Base Hospital
Physician/MICN giving medical direction), the patient will be taken to the receiving hospital of his/her
choice. If the patient is unable to determine this, the hospital designated by the private physician and/or
patient's family member will be utilized.
Paramedics and EMTs should determine where the patient normally receives their medical care and
encourage the patient to return to that hospital for medical care as long as the patient’s medical condition
allows for such transport.
2.The Paramedic/EMT/MICN/BHP should only provide the patient with alternatives for destination of
patient choice. It is inappropriate for the Paramedic/EMT/MICN/BHP to endorse specific facilities or
provide personal opinion on the quality of local facilities.
3.Health Plans - If the patient is a member of a health plan with a preferred hospital, an attempt should be
made to transport the patient to a participating facility.
4.Closest Appropriate Hospital
a.The closest appropriate hospital is defined as the closest emergency department "equipped, staffed,
and prepared to administer care appropriate to the needs of the patient" (California Code of
Regulations, Title 13, Section 1106 (b) 2).
b.Closest is defined as the shortest travel time not necessarily the closest by distance.
c.The Base Hospital Physician will have the ultimate authority concerning patient destination.
d.The closest appropriate hospital does not mean that critically ill patients always go to the closest
“receiving” hospital. They go to the closest "appropriate” hospital. The following guidelines will
help to define "appropriate":
1)Due to short transport times, the appropriate receiving facility for a life-threatening
medical situation would be a hospital with a basic emergency service (holds a special
services permit from the California State Department of Health Services). Hospitals with
basic emergency services are:
a)Adventist Medical Center Hanford (AMC-H)
b)Children’s Hospital Central California (Children’s Hospital)
c)Clovis Community Medical Center (CCMC)
d)Kaiser Permanente Hospital (KPH)
e)Kaweah Delta Medical Center (KDMC)
f)Madera Community Hospital (MCH)
g)Saint Agnes Medical Center (SAMC)
h)Sierra View District Hospital (SVDH)
i)Tulare Regional Medical Center (TRMC)
j)Regional Medical Center (RMC)
2)Rural Areas - Due to prolonged travel times to the urban area, the appropriate receiving
hospital for a life-threatening medical situation would be a hospital with a standby
emergency service (holds a special services permit from the California State Department
of Health Services). Hospitals with stand-by emergency services that are approved to
receive ambulances are:
a)Adventist Medical Center Reedley (AMC-R)
b)Adventist Medical Center Selma (AMC-S)
Exhibit L
Page 3 of 10
Subject:
Patient Destination
Policy
Number: 547
c)Coalinga Regional Medical Center (CRMC)
5.Acute Cardiac Emergency
In the event of an acute current of injury transport should be to a facility with interventional heart
catheterization capabilities. The following is a list of readings from various cardiac monitors:
•*** ACUTE MI *** (Zoll Monitor E Series)
•***STEMI*** (Zoll Monitor X Series))
•***ACUTE MI SUSPECTED*** (Physio-Control Monitor LifePak 12)
•***MEETS ST ELEVATION MI CRITERIA*** (Physio-Control Monitor LifePak 15)
Transport should be either to:
•Regional Medical Center
•Kaweah Delta Medical Center
•Saint Agnes Medical Center;
whichever has the quickest transport time, if transport time is less than 60 minutes. If transport time is
greater than 60 minutes then transport to the closest appropriate facility or consider helicopter rendezvous.
Destination is determined by:
a.Interpretation of 12-lead ECG; or
b.Base Hospital consultation if required.
6.Patients who go directly to the closest appropriate receiving hospital:
a.Any unstable or unmanageable airway (this is defined as unable to maintain a BLS airway).
Example: If the patient can be bagged via a BVM without an ET Tube or OPA, this is not an
unstable airway.
b. Any patient with CPR in progress.
c.Any critically ill or unstable patient when Base Hospital contact is not possible (i.e., Paramedic or
EMT must make the ultimate destination decision).
7. Patients who go to a non-receiving hospitals:
Patients may be transported to a non-receiving hospital only when the Base Hospital has contacted the
receiving doctor and received assurance of immediate acceptance of the patient. Such assurance should
then be documented on the Base Hospital run form.
8.Patients who go to a receiving hospital, which is not closest:
Unstable patients who request this hospital and, in the opinion of the Base Hospital Physician, the extra
travel time is not dangerous to the patient
Exhibit L
Page 4 of 10
Subject:
Patient Destination
Policy
Number: 547
C.Fresno County 5150 Holds – Considerations
1.Fresno County 5150 patient criteria for transport Crisis Stabilization Center (CSC) and Children’s Crisis
Assessment Intervention Resolution (CCAIR):
a.If the patient meets the following criteria, he/she shall be transported directly to Crisis Stabilization
Center (CSC) if age 18 or greater; or the Children’s Crisis Assessment Intervention Resolution
(CCAIR) if under 18 years of age:
•No urgent medical complaint or evidence of acute medical/surgical/trauma problem requiring
urgent treatment prior to psychotic admission.
•No alteration in mental status due to dementia or delirium.
•Glasgow Coma Score 14 or 15.
•Complete vital signs within limits (HR, RR, BP, and GCS).
•Not febrile to palpation/measurement.
•Under the influence of alcohol or drugs, patient can walk without assistance and is able to
follow verbal commands (does not apply to CCAIR).
1)Adults:
a)Pulse: 50-120.
b)Systolic Blood Pressure: 100-180.
c)Diastolic Blood Pressure: less than 120.
d)Respiratory Rate: 12-30.
2)Pediatrics:
a)Vital signs appropriate for children (policy 530.32).
NOTE: Refer to the Criteria for Transporting a Fresno County 5150 Patient Directly to Crisis
Stabilization Center (CSC) or CCAIR Screening Form attached to this policy.
Patients that Crisis Stabilization Center (CSC) cannot accept:
•Patients with dementia or delirium
•Patients with ongoing medical care (i.e., patients who require continuous oxygen use,
catheters, wired devices, etc.)
•Patients in wheelchairs that cannot move independently
•Patients with any open wound, laceration, skin ulcer, or decubitus that requires anything
more that once daily dry gauze and tape dressing
b.All other patients on a 5150 hold in Fresno County not meeting the above criteria will be
transported to Patient/Family Choice within Fresno County.
c.Patients placed on a 5150 hold are to be transported to facilities within the county where the 5150
hold was initiated.
d.The 5150 destination policy does not apply to psychiatric patients who are voluntarily requesting
evaluation (not on a 5150 hold). If the patient is not on a 5150 hold, then transport will be to a
receiving facility of their choice, which includes CSC (Fresno County only) if patient meets
criteria within this policy.
e.Veteran’s Administration
Exhibit L
Page 5 of 10
Subject:
Patient Destination
Policy
Number: 547
2.The Veteran’s Administration emergency department will accept all patients with a Veterans
Administration (VA) Identification Card or active duty Department of Defense (DOD) Card (Patient Name
Only, no dependant(s). Name of patient on card must be the patient requesting transport). No prior
approval or Base Hospital contact is necessary. If the patient requests transport to Veterans Administration
emergency department and does not have the identification noted above, contact the VA Emergency
Department directly for prior approval before the patient is transported. The complete name and the full
social security number will be required. Contact the Veteran’s Administration on Med 6 or 241-3600.
3.Patients that cannot be transported directly to the Veteran’s Administration are:
•Cardiac arrest due to trauma
•Pediatric cardiac arrest
•Trauma Center Triage Criteria
•OB patient in active labor
•Gynecological complaints and known obvious pregnancy with vaginal bleeding
•ST-segment elevation myocardial infarction (STEMI)
NOTE: INTERFACILITY TRANSPORTS ARE NOT MANAGED THROUGH THIS PROCEDURE.
III. TRAUMA PATIENT DESTINATION
A. Trauma patients shall be transported to the appropriate destination in accordance with the following chart:
TRAUMA DESTINATION CHART
n
o
p
y Glasgow Coma Score < 13 (or, in patients whose
normal GCS is less than 15, or a decrease of two
or more of the patients GCS score)
y Penetrating injury to the head
y Paraplegia
y Quadriplegia
RMC
(Consider air transport)
Assess Local Criteria
y Systolic Blood Pressure:
o Adults: < 90 mm Hg
o Pediatrics: < 80 mm Hg with signs and
symptoms of shock (Refer to EMS Policy
530.32 for estimated weight formulas or
use Broselow Tape)
y Respiratory Rate:
o Adults: < 10 or > 30
o Children: < 20 if under age 1
Assess Physiological Criteria
RMC or KDMC
(Consider air transport)
Assess Anatomy of Injury
y Penetrating injuries to neck or torso
y Flail chest
y Two or more proximal long‐bone fractures
y Amputation proximal to wrist or ankle
RMC or KDMC
(Consider air transport)
Exhibit L
Page 6 of 10
Subject:
Patient Destination
Policy
Number: 547
q
r
s
t
Assess Burns
RMC
(Consider air transport)
STABLE TRAUMA PATIENTS WITH:
y Partial/Full thickness burns > 10% TBSA
y Partial/Full thickness circumferential burns
y Partial/Full thickness burns to face, hands, feet,
major joints, perineum, or genitals
y Electrical burns with voltage > 120 volts
y Chemical burns > 10% TBSA
Assess Special Considerations
Consider transport to
RMC or KDMC
WITH A SIGNIFICANT COMPLAINT:
y Age greater than 55 years
y Anticoagulation or bleeding disorders
y Pregnancy greater than 20 weeks
y Auto vs. Pedestrian > 20 mph
y Motorcycle crash > 20 mph
Assess Mechanism of Injury
y Falls
o Adults: > 20 ft. (one story = 10 ft.)
o Children: > 10 ft. or 3 times height of the
child
RMC or KDMC
(Consider air transport)
Paramedic/Flight Nurse Judgment
WITH A SIGNIFICANT COMPLAINT
Consider RMC or KDMC
Base Hospital Consultation
Transport According to Policy
SIGNIFICANT COMPLAINT
Perseveration
Deteriorating mental status
Severe chest pain
Severe shortness of breath
Severe abdominal pain
Sustained, overwhelming “Feeling of Doom”
Exhibit L
Page 7 of 10
Subject:
Patient Destination
Policy
Number: 547
NOTE: If transport time is greater than 60 minutes for patients meeting trauma triage criteria, base hospital contact
shall be made to determine appropriate destination.
NOTE: If transport time is greater than 2 hours for patients meeting burn triage criteria, base hospital contact shall
be made to determine appropriate destination.
B.Triage Criteria
Triage criteria will determine if the patient will be transported to a trauma center or closest receiving hospital.
C.Trauma Patient Destination – Considerations
1.If the patient is in cardiac arrest from penetrating trauma in the greater Fresno or Visalia metropolitan area,
the patient should be transported to Regional Medical Center or Kaweah Delta Medical Center, bypassing a
closer receiving facility. However, if the transport time to Regional Medical Center or Kaweah Delta
Medical Center is greater than ten (10) minutes, then transport should be to the closest receiving facility
within ten minutes transport time (Refer to EMS Policy #550).
2.Trauma patients, meeting trauma center criteria, who have a transport time greater than 60 minutes to the
trauma center, will require base hospital contact for destination decision.
3.The following types of incidents should be consideration for transport to the designated Trauma Center,
based upon paramedic judgment:
a.Motorcycle Crash - Non-ambulatory with potential of significant injuries
b.Auto versus Pedestrian - Non-ambulatory with potential of significant injuries
NOTE: Paramedic judgment is based upon the paramedic’s own knowledge and experience to determine if the
patient’s condition would require transport to a designated Trauma Center due the mechanism of injury and
potential underlying injuries. The Paramedic may contact a Base Hospital for advice on destination.
4.Transport of Trauma Patients by Helicopter
A trauma patient should not be transported by helicopter unless they meet trauma triage criteria to be
transported to the Regional Trauma Center or the patient is inaccessible by ambulance (i.e., wilderness
transports). EXCEPTION: When the paramedic feels helicopter transport of the patient would be
beneficial to the outcome of the patient.
5.Burn Patients
a.The following patients should be transported directly to the Regional Burn Center (Regional
Medical Center) bypassing other hospitals if ETA to Regional Medical Center is within two hours.
1)Patients with 2o (partial thickness) or 3o (full thickness) burns that are more than 10% total
body surface area
2)Patients with 2o (partial thickness) or 3o (full thickness) circumferential burns of any body part
3)Patients with 2o (partial thickness) or 3o (full thickness) burns to face, hands, feet, major joints,
perineum, or genitals
4)Electrical burns with voltage greater than 120 volts
5)Patients with chemical burns greater than 10% total body surface area.
6. Carbon Monoxide Poisoning - Early call-ins to Regional Medical Center should be made for patients that
appear to have significant exposure to carbon monoxide poisoning (altered mental status, vomiting, and
headaches).
Exhibit L
Page 8 of 10
Subject:
Patient Destination
Policy
Number: 547
7.Trauma patients who go directly to the closest appropriate receiving hospital:
a.Any unstable or unmanageable airway (this is defined as unable to maintain a BLS airway).
Example: If the patient can be bagged via a BVM without an ET Tube or OPA, this is not an
unstable airway.
b.Any patient with CPR in progress (refer to EMS Policy #550).
c.Any critically injured or unstable patient when Base Hospital contact is not possible (i.e.,
Paramedic or EMT must make the ultimate destination decision).
IV.PATIENTS WHO REFUSE TRANSPORT TO THE APPROPRIATE HOSPITAL
A Base Hospital shall be contacted for the purpose of physician consultation on patients who meet one or more of the triage
criteria and refuse transport to the appropriate hospital. This will usually not be a problem with the acutely ill patient.
However, some patients with normal mental status may wish to be transported to a different hospital than the one selected via
the triage criteria. These situations should be treated as “Refusal of Medical Care and/or Transportation" situation (refer to
EMS Policy #546). The Base Hospital Physician, after radio contact, may allow the patient to go to the destination of their
choice, have a “Refusal of Medical Care and/or Transportation " signed or insist on transport to the designated hospital.
V. PATIENTS WHO CAN GO DIRECTLY TO AN EMERGENCY DEPARTMENT WAITING ROOM
Prehospital personnel shall utilize the emergency department patient entrance at all receiving hospitals for non-emergent
patients. Delivery of patients to the appropriate area of the emergency department is based on severity of illness.
Patients who meet the following criteria can be taken directly to the emergency department walk-in waiting room, bypassing
the ambulance entrance used for serious or critically ill patients.
•Patients 18 years old or older or minors accompanied by a responsible adult.
•Patient has normal, age appropriate vital signs (± 5%).
•Patient can sit unassisted and has reasonable mobility.
•Patient does not meet criteria for ETA call-in.
•Patient does not have IV access started by EMS.
•Patient is not on a 5150 hold or in custody.
EMS personnel must give report to a hospital employee authorized to triage, or take possession of the patient, and obtain a
signature for transfer of patient care. If there is a difference of opinion as to the appropriate waiting area, or location of the
patient, the hospital representative will make the final decision as to the disposition of the patient and provide the turnover
signature.
Exhibit L
Page 9 of 10
Subject:
Patient Destination
Policy
Number: 547
VI.SPECIAL CONSIDERATION FOR OBSTETRICS OR PREGNANT PATIENTS REQUESTING ADVENTIST MEDICAL
CENTER – HANFORD
While Central Valley General Hospital will not have an emergency department, the hospital will still be open as an in-patient
/ out-patient facility for OB/GYN services. Ambulance patients may be taken directly to Central Valley General Hospital
under the following circumstances:
•Transfers from a physician’s office when the physician requests that the patient be taken directly to Central Valley
General Hospital
•An interfacility transfer from another hospital (i.e., direct admit)
•Obstetrics or pregnancy related calls when directed by the Base Hospital (Adventist Medical Center–Hanford) to
transport directly to Central Valley General Hospital. A full standard call-in must be made to the Base Hospital on
all OB/GYN patients.
VII. SPECIAL CONSIDERATION FOR HEART HOSPTAL DESTINATION
While the Heart Hospital is a hospital within Central California EMS Region, it does not have an emergency
department and is not an approved facility for patient transports within EMS Policy and Procedures. Patients who are
requesting transport to the Heart Hospital from the prehospital setting will require Base Hospital contact to confirm
acceptance. Since the Heart Hospital is under the Community Medical Center organization, EMS personnel should contact
Regional Medical Center when requesting transport to the Heart Hospital. If attempts to contact Regional Medical Center
are unsuccessful, EMS personnel should contact another Base Hospital. Interfacility transfers involving the Heart Hospital
shall be in accordance with EMS Policy #553, “ALS Interfacility Transports”.
Exhibit L
Central California EMS Agency
Criteria for Transporting a Fresno County 5150/Psychiatric Patient
Directly to CSC or CCAIR Screening Form
Patient’s Name: ________________________________________ EMS #: __________________
Patient has urgent medical complaint or evidence of acute medical/surgical problem.
[ ] True – transport Patient/Family Choice [ ] False
Patient has alteration in mental status due to dementia or delirium.
[ ] True – transport Patient/Family Choice [ ] False
Patient has a Glasgow Coma Score 13 or less.
[ ] True – transport Patient/Family Choice [ ] False
There are lacerations with a gap of greater than 2 mm or fat/muscle visible in the wound (excludes any type of stab
wound).
[ ] True – transport Patient/Family Choice [ ] False
There are lacerations or wounds inflicted by others.
[ ] True – transport Patient/Family Choice [ ] False
Complete vital signs are within limits:
Adults:
Pulse outside range of 50-120. [ ] True – transport Patient/Family Choice [ ] False
Systolic Blood Pressure outside range of 100-180. [ ] True – transport Patient/Family Choice [ ] False
Diastolic Blood Pressure greater than 120. [ ] True – transport Patient/Family Choice [ ] False
Respiratory Rate outside range of 12-30. [ ] True – transport Patient/Family Choice [ ] False
Pediatrics:
Vital signs inappropriate for children
(Policy 530.32) [ ] True – transport Patient/Family Choice [ ] False
Patient is febrile to palpation/measurement.
[ ] True – transport Patient/Family Choice [ ] False
Is patient under the influence of alcohol or drugs.
[ ] Yes [ ] No
If yes, to under the influence of alcohol or drugs, does patient require assistance to walk.
[ ] True – transport Patient/Family Choice [ ] False
If all of the above answers are False, patient may be transported to CSC/CCAIR. Otherwise transport is
Patient/Family Choice.
Patients that Crisis Stabilization Center (CSC) cannot accept:
•Patients with dementia or delirium
•Patients with ongoing medical care (i.e., patients who require continuous oxygen use, catheters,
wired devices, etc.)
•Patients in wheelchairs that cannot move independently
•Patients with any open wound, laceration, skin ulcer, or decubitus that requires anything more that
once daily dry gauze and tape dressing
Exhibit L
Page 10 of 10
Fresno County Mental Health Plan
24/7 Toll-Free Access Line
Intuitive Database for Logging Calls
The Access Line database is a web-based application, developed with intuitive, decision-tree functionality that
will be used by the answering service provider for the collection of caller/client information received on the
24/7 Toll-Free Access Line and all other department programs utilizing the answering service, and to provide
callers with information on how to access SMHS in accordance with the State requirements. The database
contains features incorporates the State-mandated requirements related to logging initial requests for
specialty mental health services.
DATABASE SCREENSHOTS
GREETING SCREEN: User’s name will appear in the greeting based upon the user’s login information.
INTERPRETER SCREEN: After either option from the greeting menu above is selected, the interpreter
screen opens up. It contains a drop-down listing of languages and step-by-step instructions on how to
reach Language Line Services
Exhibit M
Page 1 of 10
EMERGENCY SCREEN: Questions on the “Client” tab change according to the response in regards to
whom the call is made for.
Exhibit M
Page 2 of 10
NON-EMERGENCY CALLS – ROUTING SCREEN
Exhibit M
Page 3 of 10
Exhibit M
Page 4 of 10
REQUEST NO CALL BACK SCREEN: For callers requesting only information regarding MH services or
access to MH services.
SERVICE REQUEST SCREEN:
Exhibit M
Page 5 of 10
LEAVE A MESSAGE SCREEN:
Exhibit M
Page 6 of 10
REQUEST LITERATURE/INFORMATION SCREEN:
Exhibit M
Page 7 of 10
FILE COMPLAINT SCREEN (Part 1 of 2):
Exhibit M
Page 8 of 10
FILE COMPLAINT SCREEN SCREEN (Part 2 of 2): Provides descriptions of the various types of
complaints that can be filed and offers alternative formats for the various forms.
Exhibit M
Page 9 of 10
OTHER REASON SCREEN: For calls that fall outside of the list of call types (routing screen).
BACK-END USER DASHBOARD: Logged calls are categorized by call type. Allows department staff to
retrieve and triage calls for appropriate follow-up. Features include the ability to view and edit the
logged call, provide comments on what was done with the call, and close the call out once the
appropriate follow-up/action(s) has been completed.
Exhibit M
Page 10 of 10
Exhibit N
Page 1 of 1
Exhibit O
Page 1 of 1
Fresno County Mental Health Plan
1-800-654-3937 Access Line Test Call Feedback Form
The toll-free Access Line is available 24 hours a day, seven days a week, to provide information on how
to access specialty mental health services, including services needed to treat a beneficiary’s urgent
condition. The toll-free line also provides information on how to use the beneficiary problem resolution
and fair hearing processes. This line also has language capabilities in all languages spoken by the
beneficiaries of Fresno County
TEST CALLER INFORMATION
Name of Staff Testing Line: Date of Call: / /
Fictitious Name of Caller: Time of Call: : AM PM
Fictitious Name of Client (if different): Client is a(n): Minor (under 18 years)
Adult (18 years and over)
Language of Caller/Client: English Spanish Hmong Other (Specify):
Caller’s/Client’s Phone # Provided to Operator: ( ) - None Given N/A
Reason for the call:
RESULTS OF TEST CALL
1. Did the person who took your call tell you his/her
name? Yes No If Yes, what was it:
2. Did the person who took your call ask if your situation is a crisis / emergency? Yes No
3. Did the person who took your call ask for your name? Yes No
4. Did the person who took your call ask for your phone number? Yes No
5. Foreign language test callers only: Did the person who took your call speak
your language or provide help with free language assistance services?
N/A Yes No
6. Did the person give appropriate information on how to access services? N/A Yes No
7. Did the person give appropriate phone #’s (i.e. UCWC/Exodus) to contact DBH? N/A Yes No
8. Did the person give appropriate information on how to receive literature upon
your request?
N/A Yes No
9. Did the person give appropriate information on how to file a complaint upon
your request?
N/A Yes No
ADDITIONAL COMMENTS
Exhibit P
Page 1 of 1
Fresno County Mental Health Plan
1 (800) 654-3937 Access Line - Statement of Deficiencies and Plan of Correction
Provider Name
Address
City Zip Code
Phone ( ) - Ext.
Category Summary Statement of
Deficiencies
Provider’s Plan of
Correction Completion Date
/ /
/ /
/ /
/ /
/ /
Provider’s Signature Title Date