Grand Jury Report No. 3 Fresno County Department of Behavioral Health: Will the

Funding is sensitive as it comes from Federal and State sources (Medi-Cal and grants), yet there is no contingency plan defining how spending will be cut at DBH in the event of funding cuts. Response: The Department partially disagrees with the finding. DBH agrees that the funding is sensitive and complex, however, stating the Department does not have a contingency plan is not completely accurate. DBH has developed a menu of potential changes and a mechanism to make those decisions, including bringing forth recommendations for cuts to the budget, when appropriate, to the Board of Supervisors, as the Board is ultimately responsible for setting County policy and approving the budget. In addition, DBH has maximized the Mental Health Services Act (MHSA) Prudent Reserve as allowable by regulations to prepare for changes to MHSA funding, and this is outlined in the MHSA Plan, which is updated annually and approved by the Board of Supervisors. The DBH Finance Division Manager has a standing item on the Department’s leadership team meeting agenda for monthly fiscal updates to all Division Managers, Deputy Directors, and the Director; this item provides a continuous opportunity to review key funding and budgetary matters and for all leadership team members to assist in planning. The Director and Deputy Directors meet monthly with the DBH Finance Division for routine fiscal reporting and planning, as well adjustments, as needed and within budgetary authority. Additionally, each division has a quarterly fiscal check-in meeting with the DBH Finance Division, Deputy Directors, and the Director for fiscal monitoring and planning purposes. Most of the funding sources which support Department services and operations are dynamic, not static. The current regulatory environment in the California public behavioral health environment is rapidly evolving. Preparedness for funding changes is an ongoing process, as the Department continuously updates projections of revenue increases or declines and adjusts expenditures based on actual changes in revenue where authorized in the approved departmental budget. Decisions on adjustments are made in alignment with the Department’s vision, mission, and goals and the overall County mission, always with focus on preservation of core services to the public. The Director of DBH provides frequent updates to the County Administrative Officer regarding any threats to DBH funding and would return to the Board of Supervisors with formal recommendations in the event of significant external cuts to funding. While contingency planning is regular and ongoing, DBH acknowledges that there is not a written departmental policy or document outlining the process by which we review and plan for overall funding changes and we are in the process of creating such a policy.

There is no formal system of vertical communication for DBH employees to ask questions or make suggestions and have a guaranteed response from upper management. Response: The Department disagrees with this finding. There are numerous opportunities for DBH employees to communicate with upper management and have a guaranteed response. The Director of DBH conducts a live YouTube broadcast every month to all DBH employees, which includes a standard question-and-answer segment at the end. Employees may ask questions in real time by emailing the DBH Executive Assistant who relays them to the Director live, or by asking anonymously through YouTube’s live chat feature. During the YouTube broadcast, the Director answers all questions in real time if answers are known and for any questions that cannot be answered live, the Director commits to address them by email or subsequent presentation. This broadcast date/time is typically the third Thursday of every month and the meeting invitation is sent by Outlook to all employees for their calendar. If rescheduling is required, all employees are notified by email. Employees who cannot view the broadcast live can watch the recording; the DBH Executive Assistant sends the link to the recording by email following the broadcast and employees may send in questions via email for follow up. The Department also hosts one or more annual All Staff Meetings, during which a question- and-answer section is included. The December 2024 All Staff Meeting was fully dedicated to questions and answers with invited guest, County Administrative Officer, Paul Nerland; during that meeting both Mr. Nerland and the DBH Director, Susan Holt, addressed questions directly asked by DBH employees. For calendar year 2025, two in-person All Staff Meetings are planned. Additionally, the DBH Director holds a monthly All Supervisors meeting where every supervisor in the Department is expected to attend. During these All Supervisors meetings, supervisors are encouraged to ask questions and make suggestions. Division Managers schedule quarterly meetings with their division to provide information, address questions, hear concerns and suggestions, and focus on teambuilding. As schedules permit, Deputy Directors are invited to participate in divisional meetings. Division Managers routinely provide feedback from their employees to Deputy Directors and the Director. DBH teams have regular meetings with their supervisors and Division Managers visit their teams on a regular basis, giving staff the opportunity to ask questions, seek clarification, and provide suggestions. Supervisors are encouraged to meet regularly with their managers who, in turn, are expected to communicate employee and supervisor feedback with a member of the DBH Executive Leadership Team. Supervisors are also recommended to regularly schedule one-on-one meetings with their individual team members. At all levels, team members are welcome to share information. Deputy Directors and DBH Human Resources representatives meet often with bargaining units and document all concerns and suggestions for follow up. DBH leaders circle back in subsequent meetings to share the outcome of follow up with bargaining unit representatives and employees who participate in the labor-management meetings. Team members are reminded during the bargaining unit meetings of the availability of the chain-of-command and inclusion of DBH Human Resources and encouraged to escalate any questions, suggestions, or concerns. Employees are encouraged to ask questions of the DBH Director, Deputy Directors and Division Managers via email, Teams chats, or by setting up appointments for a meeting. Deputy Directors routinely visit programs, work areas, and staff meetings specifically to hear from employees in their areas of responsibility. The Director has utilized the DBH Quality Management team (formerly known as Quality Improvement Team) to facilitate focus groups to further illicit input, perspectives, and suggestions from DBH employees. Employees working in the field have County-issued cellular phones to communicate with their supervisor or a designated supervisor or manager who may be covering in the event of the supervisor’s absence. All Division Managers are accessible by cell phone during business hours. The expectation for multidirectional sharing of information, suggestions, and questions has been communicated numerous times and in different formats in DBH. The Director, Deputy Directors, and Division Managers regularly communicate with DBH employees, responding to questions and suggestions in various formats, which have been supported and encouraged by these leaders including, but not limited to, the live Director’s Update broadcast, standing meetings, direct email, by-appointment, one-on-one meetings, labor- management bargaining unit meetings, and employee focus groups. While the Director acknowledges that communication in any organization can always improve, the Director believes that there are numerous formal and informal mechanisms for vertical communication.

The transition to SmartCare Electronic Health Record (EHR) software system has created more issues for DBH than anticipated. Response: The Department disagrees with this finding. Stating that the transition has created more issues than anticipated is not accurate, as DBH anticipated the transition would include numerous challenging issues. DBH was aware of the ambitious timeline to implement the new software, but the transition date was, by design, aligned with California’s historical behavioral health payment reform. This decision was strategically executed in order to minimize the number of changes that staff would have to make to accommodate payment reform. Implementation challenges are inherent in any transition of a healthcare system’s electronic health record; thus, DBH was proactive to prepare for and develop processes to swiftly address transition challenges as they surfaced. There are numerous employees identified as Subject Matter Experts (SME) and Expert Users throughout the Department in specialized areas and these employees received enhanced SmartCare training to serve as the first point of contact within their teams. Another layer of expertise was established in the form of Super Users, which includes representatives from DBH Compliance, Information Technology, a few Division Managers and a select few Expert Users. Throughout implementation, this group would discuss questions and determine answers, address real-time issues, and post validated information and instruction in a Teams chat with all the Expert Users. An example of a specialized Expert Users group in DBH is a group of SMEs called the Clinical Expert Users. This group was formed before SmartCare go-live and met weekly before and after go-live. Each team had their Clinical Supervisor and one other team member who were identified to serve as the SME Expert Users for their team. Although DBH is now well beyond the initial transition support needs, the Clinical Expert Users group continues to meet monthly to this day for ongoing EHR support. Other groups of classification or function-based Expert Users also met regularly throughout DBH’s preparation for and implementation of SmartCare. The Teams chat for all Expert Users is still currently maintained and accessible for any support or immediate answers which may be needed. Each DBH team maintains an identified Expert User representative who is expected to troubleshoot, train, share information with their team and to the other expert users. Both contracted and county staff participate in this process. Clinicians in the Planning and Quality Management (PQM) Division are also SMEs and provide additional support to staff when needed. PQM conducts a hands-on training for new staff who are onboarding into the EHR as new users of the system. This training, called SmartCare Onboarding for Full EHR Users, is an in-person monthly training for new hires. New hires in DBH are automatically enrolled in this training. Prior to the SmartCare go-live date, DBH Staff Development created a SmartCare training plan with links to all online trainings related to the EHR. This training plan was celebrated as an example for the rest of the counties in many cross-county meetings hosted by the Joint Powers Authority as well as the California Mental Health Services Authority (CalMHSA), which serves as the overall System Administrator of the semi-statewide SmartCare EHR. SmartCare is a semi-statewide EHR for participating county behavioral health plans and, as such, DBH participates in regular Technical Assistance calls with CalMHSA SmartCare System Administration to raise issues and to facilitate development of supports and solutions in the EHR.

DBH Field Clinicians lack sufficient training to enhance their safety and effectiveness. Response: The Department partially disagrees with this finding. New hires are required to take trainings relevant to their professional category (whether clinical or administrative) and supervisors ensure that their staff are signed up for all appropriate trainings through DBH Staff Development, Relias Learning Management System (LMS), or Neogov (County’s electronic LMS). When training needs are identified, the DBH Training Committee and/or the DBH Staff Development team (with support from management) propose solutions to address the needs. Solutions have included bringing in external trainers, utilizing internal team members to provide training, and developing a training series specific to a professional classification. For clinicians and other clinical staff, Clinical Supervisors also provide trainings in their staff meetings and in one-to-one supervision related to targeted case management, psychosocial rehabilitation, crisis intervention, documentation and other relative topics. The Clinical Supervisor Onboarding Training Guideline supports Clinical Supervisors to onboard new clinical staff and includes safety and de-escalation training. This guideline was developed through a DBH Training Committee workgroup in July 2022 and was last updated on April 16, 2024. Although this document was shared with Clinical Supervisors, it is possible that not all Clinical Supervisors have a current copy. To mitigate that risk moving forward, Staff Development will assign this training guideline to all new Clinical Supervisors through the Relias LMS and assign a Relias LMS module for all existing Clinical Supervisors on an annual basis. DBH has invested in numerous clinical training modalities and supports evidence-based practice consultation groups for specific modalities (e.g., treatment of eating disorders). Additionally, all pre-licensure clinicians receive up to three hours of clinical mentoring from experienced licensed clinicians, in addition to the training and supervision provided by their Clinical Supervisor. Clinical mentoring provides a direct process for clinical guidance, support, and coaching by a licensed clinician, which can include a wide range of clinical topics including, but not limited to, evidence-based practices, diagnostics, specific treatment interventions, and clinical management of persons who present with complex behaviors. DBH is also in the process of formalizing a written training plan for all team members, which will include safety, clinical trainings, and clear protocols for field-based service delivery for all clinical staff. Related to safety, in early 2023, the Department conducted an assessment to reinstitute Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) trainings for all DBH staff, which was previously paused due to COVID-19 and the lack of certified trainers. NCI is a certified training in nonviolent crisis intervention that teaches staff how to prevent, recognize, and respond to challenging behaviors; prioritize safety; and use physical interventions as a last resort. The training includes risk assessment, verbal and non-verbal de-escalation skills, disengagement tactics and techniques to physically intervene if other options have been exhausted. The certification training supports staff to identify stages of increasing behaviors, use evidence-based approaches with individuals presenting with crisis behaviors, and prepares staff to minimize physical interventions by using safe and advanced disengagement techniques. While the Department prepared to relaunch the NCI training, it identified and implemented other safety trainings through the Relias LMS. For example, on March 20, 2023, the Department assigned two safety trainings to all staff: 1) Strategies for Preventing and De- escalating Hostile Situations, and 2) Facing Confrontation in Customer Service. In June 2023, the Department met with a CPI representative to explore a direct delivery training model. While the Department continued efforts to create a plan for in-person NCI training, DBH Staff Development identified other trainings in the Relias learning management system. On June 30, 2023, the Department emailed all staff of the availability of safety focused trainings: 1) First Aid, 2) Safety in the Field, and 3) The Basics of Workplace Safety, and included instructions on the process for enrollment. On July 25, 2024, DBH Staff Development submitted a proposal to resume in-person NCI training, whereby the Department funds three County Human Resources (HR) Staff Development members to become CPI NCI trainers via a train-the-trainer process. The goal of DBH was to invest in an approach for training in NCI that could support all of DBH as well as other county departments who could benefit from this valuable training. County HR committed to provide 25 NCI training sessions to train over 500 staff over a span of 18 months. In February 2025, NCI training was reinstituted and offered twice per month for DBH staff. The Department’s goal is to ensure all clinical staff are trained first and after that, the NCI training will be expanded to non-clinical positions. As of June 2025, a total of 180 staff have received NCI training.

DBH’s Field Clinicians have no current information regarding known violent tendencies or criminal history of their patients prior to meeting with them. Response: The Department partially disagrees with this finding. With respect to persons previously known to the Department or referred through the justice system, information is available to clinical staff, including field staff. As a common clinical assessment practice, information related to a person’s criminal history or violent behavior, when disclosed or otherwise made available, would be documented and available in the clinical record. Thus, for persons having received a past service from the Department, a new team member who is to meet with a person for the first time has access to those records. For individuals who are specifically referred to the Department by the criminal justice system, those referrals typically come with details of criminal history. The Department agrees that for persons who are accessing our system of care for the first time, information related to potential for violence and criminal history is not available ahead of time. Risk assessment is a standard clinical procedure in every initial assessment for those accessing the system of care for the first time and in every reassessment for persons returning to services after a hiatus.

There are insufficient or outdated supplies provided to DBH clinicians working in environments outside of the office including complete first aid kits and Narcan. Response: The Department agrees with this finding.

DBH is not maintaining the most current information on its website as reports located on the website are aged and require updating. Response: The Department agrees with this finding.

The Auditor - Controller / Treasurer-Tax Collector’s office and DBH Finance/Accounting division have a different perception as to the timing of reimbursements into the County’s general fund. Response: The Department partially disagrees with this finding. In July 2023, a new county behavioral health payment method was implemented by California, commonly known as “payment reform.” This historic reform completely changed the process by which counties are paid for specialty mental health services from a cost-based reimbursement methodology, subject to retrospective cost settlement often up to ten years in arrears, to a fee-for-service methodology with an intergovernmental transfer process. DBH notified Assistant CAO, Greg Reinke and Deputy Auditor, Enedina Garcia of the upcoming change in FY 2022-23. However, DBH agrees that there was some confusion between the departments in FY 2023- 24, as the entire process was new to both DBH and the Auditor-Controller/Treasurer-Tax Collector’s (ACTTC) offices. DBH, the County Administrative Office, and the ACTTC held recurring meetings in FY 2023-24 to address this. As of the publication of the Civil Grand Jury Report, the offices of DBH and ACTTC had long since resolved the initial confusion on timing of reimbursements. Nonetheless, DBH acknowledges the complexities of payment reform and the initial confusion that resulted across departments. The Civil Grand Jury report erroneously stated that at one point, DBH owed the County general fund over $200 million. DBH records confirm that while there were limited and isolated months of high dollars due to the general fund, the Department’s portion never exceeded $200 million, and most months were significantly lower than that figure.