INVOICE

COUNTY OF SAN DIEGO Health and Human Services Agency CLAIM FOR REIMBURSEMENT Do Not Modify Performance Outcome Payment Contractor: Project: HQ Address: Contract No. Mental Health Systems Inc. CalWORKs Mental Health Services 9465 Farnham, San Diego, CA 92123 45876 Report Period: From: Prepared By: Title: Telephone No.: Term of Current Amendment: From: 7/1/2006 1-Jun-07 To: 30-Jun-07 To: 6/30/2007 TOTAL PAYMENT Pay Points 1. % of referred WtoW clients offered screening (3.1.1): Pay Point Ref # screenings offered Data for Report Month Actual Percentage Target Percent Achieved #DIV/0! # referrals 1.1 % of clients referred, who are screened (3.1.2): 100.00% #DIV/0! #DIV/0! screenings: referrals: 0 #DIV/0! 50.00% #DIV/0! #DIV/0! 2. % of clients offerred assessment Appointments appointment w/in 5 wking days of offered w/in 5 screening (3.2.1): days: #DIV/0! # Screenings: 0 100.00% #DIV/0! #DIV/0! 2.1 % of clients screened receiving assessment (3.2.2): # Assessments: # Screenings: 0 #DIV/0! 55.00% #DIV/0! #DIV/0! 3. % of clients offered services (3.3.1): # offered Svcs: # Clients: # Clients assisted: #DIV/0! 100.00% #DIV/0! #DIV/0! 4. % of eligible clients that were assisted in applying for SSI (3.4.1): #DIV/0! # Eligible Clients: 100.00% #DIV/0! #DIV/0! # Clients 5. % of eligible clients who assisted: demonstrate improved mental health (3.5.2): # Eligible Clients: # Clients 6. % of eligible clients who demonstrate increased employment assisted: readiness (3.6.2): # Eligible Clients: #DIV/0! 50.00% #DIV/0! #DIV/0! #DIV/0! 60.00% #DIV/0! #DIV/0! TOTAL PAYMENT: Monthly invoices may exceed $250,000 only to the same extent that prior, approved, monthly invoices were under $250,000. #DIV/0! Year to Date Credit Total COUNTY OF SAN DIEGO Health and Human Services Agency CLAIM FOR REIMBURSEMENT Do Not Modify Performance Outcome Payment COMMENTS: IMPORTANT: Claims submitted incomplete (without MPR), incorrect, or containing mathematical errors will be returned to contractor for correction(s). Contractor Certification on Exclusions and Debarment Lists: I certify, under penalty of perjury under the laws of the State of California, that no employee providing services under the terms and conditions of this contract is currently listed on the GSA Excluded Parties Listing or the OIG List of Excluded Individuals/Entities. Contractor Certification on Contract Expenditures and Services: I hereby certify that the above Pay For Performance services for which payment is requested were incurred in carrying out the objectives of the contract, are authorized in the approved contract and were performed in accordance with the Agreement. Date: CURRENT INVOICE Print Name: PERCENT OF ANNUAL CONTRACT CLAIMED: Signature: Title: CONTRACT SERVICES USE ONLY Contract Staff Initial: Contract Administrator Signature: Date: TOTAL CLAIMED YEAR TO DATE UNEXPENDED BALANCE $0 0% CONTRACT SERVICES USE ONLY DATE AMOUNT PAID Initial REF. DOC. TOTAL (DIFF/OWED) PO#_____________________ Approved for Payment: $______________________ Amount Manager/Authorized Representative: ______________ Date __________________________ _______________________ Printed Name Signature CalWORKs Behavioral Health Centers Service Summary for June 07 MHS, Inc Category Referrals: Screenings: Assessments: New cases this month: Total open cases: Cases with Dual Diagnosis: Cases with Domestic Violence: Open Cases involved in employment related activities: Open cases employed: Cases Closed: Closed cases involved in employment related activities: CRF UPAC Totals Closed cases employed: Outreach Contacts: Clients Medically Exempt: Mental Health Systems, Inc. Service Summary for June 07 CalWORKs Behavioral Health Centers Category Oceanside East Escondido South Totals County 1310 ACS 8530 ACS 385 Maximus 690 Union Plaza Ct. La Mesa Blvd., N. Escondido Blvd. Oxford St. Chula Oceanside, CA Ste 209 La Mesa, Escondido, CA Vista, CA 92054 CA 91941 92025 91911 Referrals: Screenings: Assessments: New cases this month: Total open cases: Cases with Dual Diagnosis: Cases with Domestic Violence: Open Cases involved in employment related activities: Open cases employed: Cases Closed: Closed cases involved in employment related activities: Closed cases employed: Outreach Contacts: Clients Medically Exempt: Community Research Foundation Service Summary for June 07 CalWORKs Behavioral Health Centers Central Region Category Referrals: Screenings: Assessments: New cases this month: Total open cases: Cases with Dual Diagnosis: Cases with Domestic Violence: Open Cases involved in employment related activities: Open cases employed: Cases Closed: Closed cases involved in employment related activities: North East 4370 South East 1750 South East 4588 54th Street and 73rd 5th Ave. San Market St. San Diego, CA 92101 Diego, CA 92102 North Central Kearny Villa, Aero Drive, and Mission Gorge Totals Closed cases employed: Outreach Contacts: Clients Medically Exempt: UPAC Service Summary for June 07 CalWORKs Behavioral Health Center Central Region - Northeast Category Referrals: Screenings: Assessment New cases this month: Total open cases: Cases with Dual Diagnosis: Cases with Domestic Violence: Open Cases involved in employment related activities: Alliance for African Assistance North East 4370 5952 El Cajon Blvd 54th Street San Diego, CA 92115 North East 5001 73rd Street San Diego, Ca. 92115 South East Ave. 92101 Central Region- Southeast 1750 5th San Diego, Ca. S. East 4588 Market St San Diego, 92102 Open cases employed: Cases Closed: Closed cases involved in employment related activities: Closed cases employed: Outreach Contacts: Client Medically Exempt Health Centers or June 07 tems, Inc. or June 07 Health Centers Foundation or June 07 Health Centers UPAC mmary for June 07 havioral Health Center Central Region- Southeast Maximus 690 Oxford Chula Vista, Ca. 91911 North Central North West 7345 Linda Vista Rd., Ste E San Diego, CA 92101 Catholic Charities Kearny Villa Rd. East ACS El Cajon Totals 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0 0 1 COUNTY OF SAN DIEGO Health and Human Services Agency Adult And Older Adult Mental Health Services Contractor: Contract Number: Program Name: MONTHLY STATUS REPORT (MSR) - SAMPLE OF CURRENT MSR AND MONTHLY INVOIC Mental Health Systems, Inc. Report Month/Yr: 45876 RU Number(s): CalWORKS Date Submitted: Instructions: All reports must be received by the 15th calendar day of the month. Please submit MSR to: AND MHS-COTR.HHSA@sdcounty.ca.gov Program 1. NOTEWORTHY ACTIVITIES/UNUSUAL EVENTS - Extraordinary accomplishments, awards and positive events. Unexpec management incidents. Include any CCISC efforts here (staff training, signing of charter/consensus document, completion of C identification of program leads, development of welcoming policy, etc.). If none, please write "None" below. 2. COMMUNITY OUTREACH /COLLABORATION WITH OTHER AGENCIES/EDUCATION REGARDING SERVICES - Outre purpose of providing information regarding access under the Mental Health Plan to beneficiaries and providers. Providers shou "Outreach" category for health fairs, educational presentations, conferences or other venues where staff shared information reg eligibility to clients or providers, e.g. outreach to the underutilizing populations listed below. If none, please write "None" below What Homeless - Mentally Disabled Underserved Populations (cultural or linguistic) Hard to Reach Individuals (rural residents or the older adults) Other (specify) 3. CLIENT SUGGESTIONS and PROVIDER TRANSFER REQUESTS and NOA-A Logs - Complete the Logs if appropriate. A) applies to MediCal programs only. This notice should be given to the client when a face-to-face assessment was completed medical necessity criteria for admission into Specialty Mental Health Services. Please state the number of NOA-As given. If n below. 4. PROGRAMMATIC ISSUES or POTENTIAL PROBLEMS and ACTIONS INITIATED TO SOLVE OR MITIGATE THEM - Cu discussion with Program Monitor. If none, please write "None" below. 5. QUALITY IMPROVEMENT ACTIVITIES - Include activities related to Improvement in Quality of Care and/or Services, e.g. C Improvement Projects. If none, please write "None" below. 6. POSITION LISTING/CULTURAL COMPETENCY - California Department of Mental Health requires the County of San Die cultural competency of service providers of Specialty Mental Health services. To meet this requirement, contractors are require Competency Report (CCR) twice in a fiscal year : (1) June Report (covering staff trainings from July through June, for all staff employed as of 6/30) and (2) December Report (covering staff trainings July through December, for all staff employed as of 12/31). For the June report only , please indicate your correction plan for any current staff who did not receive the expected 4 hours C Refer to your contract budget documents: Schedule I for budgeted positions and Schedule II for Consultants (if used as direct s 7. STAFF CHANGES - Specify if hire or termination during the report month. List position, name and credential, date of hire/te ethnicity/languages spoken. If none, please write "None" below. 8. STAFF DEVELOPMENT/TRAINING - Employees who attended a training session, seminar, or workshop. List staff name, c hours. If none, please write "None" below . 9. STATUS OF MONTHLY REPORTING REQUIREMENTS - Narrative and statistical description of accomplishment of outco statement of specific outcome objective and attach a summary of the year-to-date information as appropriate. Refer to particul in the current Outcome Standards. 10. Service Units and Billing Units Refer to your contract document (Contract Budget Summary) to obtain annual budgeted units. Use InSyst report MHS 831 to obtain your actual units for the report month and year-to-date (YTD). Percent (%) Objective Complete - YTD actual units divided by annual budgeted units expressed as a percent. These red cells (Program Number/Name) Service Units Service Function MHS Med Support Crisis Intervention C M Brokerage Rehabilitation Total Annual Budget Prior Month YTD Report Month Actual YTD Actual % of Objective Complete Annual Budget Billing Community Service MAA Screening Total COMMENTS on discrepancies, etc.: 11. Statistical Information (Overwrite with Program Number/Name) Report Item Admissions - Total number as of last day of report month Discharges - Total number as of last day of report month Active cases - All open cases as last day of report month Unduplicated clients - Total unique served during report month. Serious Incident Reports - Total for the report month Budgeted FTE Direct Service Staff - Total number (excluding consultants) . Actual FTE Direct Service staff - Total number as of the last day of the report month. Do Average Caseload per Actual Direct Service Staff FTE Use InSyst MHS 206-A for number of admissions ("Open"), discharges ("Closed"), active cases ("End Load"), and Unduplicate Report Month Name and Title of Person Completing this Form FOR COUNTY USE ONLY Date Received: COMMENTS: Date Revision Received: EGO s Agency ealth Services RENT MSR AND MONTHLY INVOICE Report Month/Yr: June 07 RU Number(s): Date Submitted: 7/13/07 Please submit MSR to: Program Monitor wards and positive events. Unexpected occurrences or risk onsensus document, completion of COMPASS, CODECAT, rite "None" below. ON REGARDING SERVICES - Outreach services are efforts for the iaries and providers. Providers should use the Monthly Status Report es where staff shared information regarding service access or If none, please write "None" below. Where Health Fairs Educational Presentations Conferences Other Venue - Complete the Logs if appropriate. Note: Notice of Action-A.(NOAe-to-face assessment was completed and the client does not meet e the number of NOA-As given. If none, please write "None" O SOLVE OR MITIGATE THEM - Current concerns that warrant Quality of Care and/or Services, e.g. Chart Reviews, Peer Reviews, Health requires the County of San Diego to provide information on requirement, contractors are required to complete the Cultural of 6/30) and ed as of 12/31). d not receive the expected 4 hours Cultural Competency Training. II for Consultants (if used as direct service staff). , name and credential, date of hire/termination, and minar, or workshop. List staff name, course title and the number of scription of accomplishment of outcome objectives. Include a tion as appropriate. Refer to particular service modality as delineated nits. ate (YTD). essed as a percent. These red cells are calculating cells, DO NOT Billing Units Prior Month YTD Report Month Actual YTD Actual % of Objective Complete cases ("End Load"), and Unduplicated clients ("Unique Cases"). Report Month Year to Date Phone No.