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Home My WebLink About20131876.tiffW. Troy Hause Attorney at Law The Greeley Building 710 Eleventh Avenue, Suite 205 Greeley, Colorado 80631 Telephone: (970) 351-6711 Facsimile: (970) 353-4025 December 16, 2013 Weld County Department of Human Services Attn: Judy A. Griego, Director PO Box A Greeley, CO 80632 Re: 2013-2014 Weld County Department of Human Services Agreement Dear Ms. Griego: I am writing this letter as notice of termination of my contract as mediator, with the Weld County Department of Human Services. I have been elected as the newest District Court Judge for Weld County District Court. Effective December 31, 2013, I will be closing my private practice and no longer will be providing mediation or legal services. If you have any questions or I can be of any further assistance, please do not hesitate to contact me. Sincerely, W. Troyfause WTH/kfr Cc: Tobi Vegter .z -3o -i3 r. 7 ao/3- /274. NR OO By RESOLUTION RE: APPROVE ELEVEN (11) CHILD PROTECTION AGREEMENTS FOR SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with eleven (11) Child Protection Agreements for Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and the providers listed within Exhibit "A", commencing June 1, 2013, and ending May 31, 2014 with further terms and conditions being as stated in said agreements, and WHEREAS, after review, the Board deems it advisable to approve said agreements, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the eleven (11) Child Protection Agreements for Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and the providers listed within Exhibit "A", be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreements. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 22nd day of July, A.D., 2013, nunc pro tunc June 1, 2013. BOARD OF COUNTY COMMISSIONERS WEL. i� ', COLORADO ATTEST: Weld County Clerk to the Board County Attorney Date of signatureAUG 2 3 2013 eel // am F. Garcia, Chair ouglas ademacher, ro-Tem arbara Kirkmeyer 2013-1876 HR0084 MEMORANDUM DATE: July 18, 2013 TO: William F. Garcia, Chair, Board of County Comm. siop@rs FROM: Judy A. Griego, Director, Human Servic SUBJECT: Child Protection Agreements for Services between the Weld County Department of Human Services and Various Providers Enclosed for Board approval are Child Protection Agreements for Services between the Department and Various Providers. These Agreements were reviewed under the Board's Pass -Around Memorandum dated May 8, 2013, and approved for placement on the Board's Agenda. There are a total of 67 agreements with various providers; the following represent the first 10 agreements received leaving 57 agreements needing to be signed by the Board Chair. The major provisions of these Agreements are as follows: No. Provider Program Area/ Funding Source PY13-14 Rate(s) 1 Collaborative Services for Change, PC 06/01/13 —05/31/14 Sexual Abuse Treatment (Offense Specific) Core $85.00/Session (Therapy — Individual or Family) $1,200.00/Episode (Evaluation) $65.00/Session (Therapy — Group) $85.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) $85.00/Month (Case Management) 2 Collaborative Services for Change, PC 06/01/13 - 05/31/14 Mental Health Services $85.00/Session (Therapy — Individual or Family $100.00/Session (Eye Movement Desensitization and Reprocessing-EMDR) $85.00/Month (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) $85.00/Month (Case Management — When Applicable) 3 Denver Children's Home 06/01/13 - 05/31/14 Day Treatment Services Core $1,650/Month 4 Family Matters of Colorado, LLC 06/01/13 - 05/31/14 Life Skills Core $45/00/Hour (Safe Exchange, In Office) $75.00/Hour (Safe Exchange, Out -of -Office) $75.00/Hour (Monitored/Supervised Visitation, In Office) $105.00/Hour (Monitored/Supervised Visitation, In Home) $110.00/Hour (Therapeutic Visitation, In Office) $140.00/Hour (Therapeutic Visitation, In Home) $140.00/Hour (Parenting Skills) $110.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) 5 Family Matters of Colorado, LLC 06/01/13 - 05/31/14 Mental Health Services Core $110.00/Hour (Therapy — Individual or Family — In Office) $140.00/Hour (Therapy — Individual or Family — In Home) $i 10.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) 6 Greeley Counseling Center 06/01/13 - 05/31/14 Mental Health Services Core $1,470.00/Episode (Psychological Evaluation -In Office, Adolescent or Adult) $1,780.00/Episode (Psychological Evaluation - Out of Office, Adult or Adolescent) $1,000.00/Episode (Parental Fitness Evaluation) $183.75/Hour (Partial Evaluation) $168.00/Hour (Interactional Evaluation) $120.00/Hour (Therapy Individual/Family) $120.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) $160.00/Hour (Crisis Intervention Services) $140.00/Hour (Case Consultation) 7 Leahy Neurofeedback. Center, LLC 06/01/13 - 05/31/14 Mental Health Services (Neurofeedback) Core $100.00/Session/Client (4 Clients/Day) $80.00/Session/Client (5 Clients/Day) $66.67/Session/Client (6 Clients/Day) $57.14/Session/Client (7 Clients/Day) $50.00/Session/Client (8 Clients/Day) $44.44/Session/Client (9 Clients/Day) $40.00/Session/Client ( 10 Clients/Day- Greeley or per sessions/client-Lakewood) $36.36/Session/Client (11 Clients) $33.33/Session/Client (12 Clients) $35.00/Episode (Qlk Test) $60.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) 8 Barry R. Lindstrom, Ph.D, LLC 06/01/13 - 05/31/14 Mental Health Services Core $325.00/Hour (Evaluation) $125.00/Hour (Individual Therapy - Ph.D.) $65.00/Hour (Individual Therapy - M.S.) $150.00/Hour (Family Therapy - Ph.D.) $75.00/Hour (Family Therapy - M.S.) $150.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting, Case Consultation-Ph.D.) $75.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting-M.S.) $125.00/Hour (Clinical or Educational Staffing — Ph.D.) $75.00/Hour (Clinical or Educational Staffing — M.S.) 9 Truth Corporation DBA Accountability Polygraph Services. 06/01/13 - 05/31/14 Polygraph Services Core/CW Admin $250.00/Polygraph (Sex History, Issue Specific, Maintenance) $100.00/Polygraph (Travel Outside of the Denver Area) 10 Victor H, Cordero, Psy.D., P.C. 06/01/13 -05/31/14 Mental Health Services Core $1,200.00/Episode (Psychological or Psychosexual Evaluation) $800.00/Episode (Mental Health Evaluation) $800.00/Episode (Interactional Evaluation, One Parent/One Report) $500.00/Episode (Additional Cost/ Interactional Evaluation, Two Parent/One Report) $350.00/Hour (Partial Evaluations) $100.00/Session (Individual Therapy 50 - Minute Session) $120.00/Session {Family Therapy, 50 -Minute Session) $120.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) 11 W. Troy Hause Attorney -At -Law 06/01/13 - 05/31/14 Mediation Services CW Admin $200.00/Hour (Mediation Services) If you have any questions, give me a call at extension 6510. PY-13-14-CORE-0158 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY Utf'AKTIVIti11T OF i-illIVIAIII SERVICES AND COLLABORATIVE SERVICES FOR CHANGE, PC This Agreement, made and entered into the _ day of June, 2013, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Collaborative Services for Change, PC, hereinafter referred to as the "Contractor". W ITN ESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Sexual Abuse Treatment (Offense Specific); and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit E "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. PY-13-14-CORE-0158 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit E of this Agreement in accordance with criteria established by the Department. CONTRACTQR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and 2 PY-13-14-CORE-0158 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the beneflis cif, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and ▪ Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that sjhe has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used. under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE-0158 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents, warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8.17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit D which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE-0158 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PL and PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and jor supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 x PY-13-14-CORE-0158 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if 6 PY-13-14-CORE-0158 performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 15. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Marci Brewer, LCSW Name 17. Notice Administrator Title Clinical Director/Co-Owner Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute persons) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Marci Brewer, Clinical Director/Co--Owner 2480 W. 26th Avenue, Suite 130-B Denver, CO 80211 (303) 433-0188 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5).calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services.. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PV -13 -14 -CORE -x158 19. Termination This Agreement may be terminated at any time by either party giving thirty (3) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the 8 PV -13 -14 -CORE -0158 CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through of -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless. in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. 9 PY-13-14-CORE-0158 CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0158 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board By: Deputy Clerk o y Attorn ey WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 11 BOARD OF COUNTY COMMISSIONERS WELD COt, N, 'FY/CQ.,LOR400 m F. Garcia, Chair CONTRACTOR: By: JUL 2 2 2013 Contractor L-C��0..JJ�CT i Z_e.,� Title Y o ity &c/3 -/87& PY-13-14-CORE-0158 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide offense specific services to clients referred by the Department, in the Denver area. Services include intake assessments, offense specific evaluations, individual, family and group therapy, specialty services for special needs and developmentally disabled youth. 2. All services will be provided by Marci Brewer, LCSW, and/or Jeff Kisicki, LCSW. 3. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. if after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 4. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. S. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 6. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 7. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TOM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 8. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 12 PY-13-14-CORE-0158 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $85.00/Session (Therapy - Individual or Family, 50 -Minute Session) $1,200.00/Episode (Evaluation) $65.00/Session (Therapy - Group, 90 -Minute Session) $85.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) $85.00/Month (Case Management) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit E. CONTRACTOR shall submit. all. itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit E of this Agreement in accordance with criteria established by the Department. 13 PY-13-14-CORE-0158 b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 14 PY-13-14-CORE-0158 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 15 PY-13-14-CORE-0158 fla .• «a a aM at eta .iwwwa- 1r r17t1AlIGlIVr VMt.f.V111CJ CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 16 PY-13-14-CORE-0158 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service.. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 17 PY-13-14-CORE-0158 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Fiorez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 18 PY-13-14-CORE-0158 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Address: Billing Contact: Phone Number: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANTTO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAMAAAAAAA AA AAA AAA AAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: / Core & Service Contract Coordinator Date 19 a) a Q - C N- 0 }, a) r tf) re r CD U=t Z ?—t. N a o O tor. c%1 Z" X cu o � 20 CO aa�co :r �,CU CO a)C" O r- ob co -,co 2do�M 0 S IN EXCEL AND WILL BE SENT TO CONTRACTOR.) PY-13-14-CORE-0158 0 tv a) -a) c © a) 2 co co CL) 2 C 2 For Use By Human Services Only WOW WOO Monthly Total (Calculates automatically) o oo M I 1 II l 1 t 1 i t I Ill 0 o M L tQ a) O L C CC a= O D rs) N N CV co L L a • •O co U O W N Q2 Oda -.--. a) a) .� Oou�oo a 0 TOTALS (Calculate Automatically) Approved End Date (Per referral) O) O N O 1 CO Approved Start Date (Per referral) O) O O N CO Household Number (Per referral) 555555 , Trails Case ID (Per referral) CO GO CO U) CO Client Name (Per Referral) SAMPLE ENTRY: Doe, John v ILI a cc 5 O ▪ Z tn O g c? w • ? F ' .71 P cc d V 0. > O wag h Z a LLt • Q 0 l- W PY-13-14-CORE-0158 in v U a) N a) 2 a- ) L O C O a) O In U Q) N Q) a f6 Q L 0 C. O R 8 a cts U 4.2 Q) J a r., h Q) H "4.C C N C 'U Q 0 Q 1Y H Z 0 2 C E t Q a) En Q) -C 4-. .i� N i O _C M CU in C O N N a) N O L O t X CU -0 a) V x a .t+ O C N N L w C Q) C 0- 0 W O i«. L O ▪ m 0.1 to O l6 A./ CU Q O V U f9 N Q) C Section I: (To be completed by the CONTRACTOR) Total Hours Billed C CU L 1— Primary Client billed: Phone Number Your Agency's Contact Person: Household Number: SECTION ii (To be completed by client) O 4-0 Q) .Q CU 4-0 0 C O 4=1 O C a) L CD O_ -C L ✓ a) C N 4- O W - O • ▪ (A O a) - b�.Q C a) C s N Cu) n� N W y O O + -▪ ' a1 V • a) s L • O 14- O �C 0 .N 1- a) c 4 0 (1) a� CC t/1 O }+ N CU > itS a) 4▪ -0 ,cn— bA d4 C 0 0 s C O a) .4.a y. N a1 s ✓ .0 a) a) V a) d V) E C a) CU a. 0 N N aJ i L 0 to E Ut C a1 s 3 .C ✓ 0 E a) O h E O ci U S it �CU L CO C:. Q 2 O U 0 4- U O a Number of Hours of Service Provided Hours of Service (Ex. 1:OO -- 2:30) C the month of service. PY-13-14-CORE-0135 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND COLLABORATIVE SERVICES FOR CHANGE, PC itrifr le too This Agreement, made and entered into the day of 2013, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Collaborative Services for Change, PC, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013 upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 cc7T/. -APZ PY-13-14-CORE-0135 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and 2 PY-13-14-CORE-0135 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals:\ i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. H. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and PY-13-14-CORE-0135 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents, warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE-0135 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. General Liability (PL and PD) (Minimum). o Combined single limit- $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE-0135 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if 6 PY-13-14-CORE-0135 performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Marci Brewer, LCSW Name 17. Notice Administrator Title Clinical Director/Co-Owner Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Marci Brewer, Clinical Director/Co-Owner 2480 W. 26th Avenue, Suite 130-B Denver, CO 80211 (303) 433-0188 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0135 19. Termination This Agreement may be terminated at any time by either party giving thirty (3) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of theirgoverning bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of 8 PY-13-14-CORE-0135 interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality 9 PY-13-14-CORE-0135 agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0135 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board CONTRACTOR: WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 11 BOARD OF COUNTY COMMISSIONERS WELD COUN,TY;-CO?RADO — ,—T_Wiliam F. Garcia, Chair By: Contractor C.c —o-c 1c - $ Clinlcc Title &tip/2 PY-13-14-CORE-0135 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide mental health services to clients referred by the Department, in the Denver area. Services include individual therapy, family therapy, and Eye Movement Desensitization Reprocessing (EMDR) to address specific problematic issues that may include, but are not limited to, abuse recovery, anger management, trauma recovery, behavior disorders, mood disorders and social skills interventions. 2. All services will be provided by Marci Brewer, LCSW, and/or Jeff Kisicki, LCSW. 3. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 4. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 5. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 6. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 7. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 8. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 12 PY-13-14-CORE-0135 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $85.00/Session (Therapy - Individual or Family, 50 -Minute Session) $100.00/Session (Eye Movement Desensitization and Reprocessing-EMDR, 90 -Minute Session) $85.00/Month (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) $85.00/Month (Case Management - When Applicable) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. 13 PY-13-14-CORE-0135 b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 14 PY-13-14-CORE-0135 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 15 PY-13-14-CORE-0135 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate,. CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 16 PY-13-14-CORE-0135 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 17 PY-13-14-CORE-0135 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7`h of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 18 PY-13-14-CORE-0135 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month /Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 19 PY 13-14 CORE -0135 0 QN LL H z 0 U 0 H f — z W Cl) CO J J a Z J W UX U 2 Q) (C U 0 E Y U- O J E a) a) i— t) ci'U RS �2+ o.E� (3 a) J Z. z c 4 W O 0 J teCL D 0 a) L U O y 2 co a) a) J x LU (13 a) U 0 (1) ca c 0 0 d0 For Use By Human Services Only Comments Monthly Total (Calculates automatically) 300.00 IIIIIIIIIIIIII O O O O co '5 (II O o_ C CC n2 O a Ls)4_, N w O r_ U -O 7 E2 C '5 O c D a) Q = o CL N N I O U Q) L 0 OU) < N co O 0) 0» TOTALS (Calculate Automatically) Approved End Date (Per referral) 0) O O N O M cO Approved Start Date (Per referral) rn 0 O N (0 Household Number (Per referral) in In in LU Trails Case ID (per referral) 1654888 Client Name (Per Referral) SAMPLE ENTRY: Doe, John • WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0135 CONTRACTED SERVICES CLIENT VERIFICATION FORM N z al v al O 01 O 0 al V a ai O C E } a `o N a) 0- 0 al V z al 0 E v Y E o C 0 0 U N aw v al E 0 7 E L C O E V 2 al a1 L Ca C a -o 5' L al yN C c a1 .) G O 0 C E a] N 0 al C a v L a) a] 0 al 0 N 7 O L E E E m m m 0 C U1 2 al c E a a E C O a) U a) J C al U C 00 U aJ o. 0 R a] L a E 0 m C S Section I: (To be completed by the CONTRACTOR) Total Hours Billed 0 Primary Client billed: Phone Numbe Household Number: SECTION II (To be completed by client) 0 O 0 0 U 8 4 O N b 8 Rai 0 F 0 U a 7) 0 b b c. d C) a N a •C ci 7 a) •;•'D 0 H ✓ a) O E ea a) C_ 0 Q�Q ai 0 a) C . L O 0 Ho `c 5 V N U4 e a+ � Client/Participant Signature (Please have all those attending sign. In the case of a child who is not able to sign, please have someone sign for the child; i.e., Sally Smith by Gregg Jones, Foster Parent) Number of Flours of Service Provided Hours of Service (Ex. 1O0 - 2:30) CI 00 C 0 O L 0 E L O a) al .0 d co m m N E C al m o. 7 a m Q .0 c a) a 00 E .0 N al L 00 C .e T C 0 E O E 0 0 Y u C a♦ V a, L 1a 1- V u II PY-13-14-CORE-O225 gOZ, i inr CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND DENVER CHILDREN'S HOME This Agreement, made and entered into the day of . 2013, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Denver Children's Home, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Day Treatment Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1.2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 a)e/.3-/)76 PY-13-14-CORE-0225 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7`h day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.• and 2 PY-13-14-CORE-0225 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AI DS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. Colorado Revised Statute (C.R.5.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds, c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE-0225 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(6). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE-0225 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease, covering all employees at work site. General Liability (PL and PD) (Minimum). o Combined single limit -$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE-0225 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 6 PY-13-14-CORE-0225 b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Rebecca A. Hea, Psv.D. Name 17. Notice Administrator Title Executive Director Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 1970) 352-1551 18. Litigation For Contractor: Rebecca A. Hea, Executive Director 1501 Albion Street Denver, CO 80220 5303) 320-8619 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0225 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §524-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0225 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-13-14-CORE-0225 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0225 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: • Weld County Clerk to the Board • WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: DENVER CHILDREN'S HOME 11 BOARD OF COU COMMISSIONERS WELD COUIy,TY, COO ADO By: liam F. Garcia, Chair JUL 2 2 2013 Atte.„, (22kti Rebecca A. Hea, Executive Director 0V3-/826 PY-13-14-CORE-0225 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide comprehensive non-residential, highly structured Day Treatment Services to female and male children and youth, as referred by the Department. 2. The target population for services is children and youth, ages 10-18, which are unsuccessful in the public school setting as a result of behavior, emotional and/or psychological issues, and/or impaired family functioning. 3. Services will be provided at 1501 Albion Street, Denver, CO 80220. CONTRACTOR is licensed by the Colorado Department of Human Services State Child Care Licensing (License Number 49551). 4. Services under this agreement include: a. Development and implementation of a treatment plan within 30 days of initial client contact. The treatment plan is subject to approval by the Department. b. Education Program/Structured Summer Program (Ongoing) c. Family Therapy (1x/week) d. Individual Therapy (1x/week or 2x/week if Family Therapy is not applicable) e. Individual Counseling/Crisis Intervention (1x/week or as needed) f. Affective Education (5x/week) g. Psychiatric Consultation (As needed) h. Medication Management (As needed) 5. Services under this agreement do not include: a. Transportation 6. The classroom environment will provide a therapeutic milieu to address behaviors as they arise. 7. Referred children and youth will receive services for approximately four (4) to six (6) months. Length of services is dependent upon the referred child/youth's daily/weekly progress, individual/family needs and availability of funding. S. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 9. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 10. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues; missed appointments; failure to appear for services; or any significant information pertaining to the client and/or service. Areas of concern should be reported immediately to the referring caseworker AND should be reported on the required monthly progress report. 12 PY-13-14-CORE-0225 11. CONTRACTOR will submit progress reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise agreed to by the Department. 12. CONTRACTOR will provide a Discharge Report to the Department within ten (10) working days following the closure of the service, and will document in detail the outcome of the service and any ongoing recommendations. Reports will be submitted per the online format required by the Department, unless otherwise agreed to by the Department. 13. CONTRACTOR will participate in team reviews of ongoing services as needed. These will primarily include general staffings and Family Engagement/Family Team meeting, and are not considered billable hours. CONTRACTOR may appear by phone. 13 PY-13-14-CORE-0225 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $1,650.00/Month (Pro -rated for any partial month of service.) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7`h day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 14 PY-13-14-CORE-0225 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 15 PY-13-14-CORE-0225 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs shoulddocument ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 16 PV -13 -14 -CORE -0225 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 17 PY-13-14-CORE-0225 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 18 PY-13-14-CORE-0225 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month /Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: / _ Core & Service Contract Coordinator Date 19 PY-13-14-CORE-0225 0 ) 0 co ) \ CI)} 2 u_ ID ID §} E )f\ 0z 2§§ //\ / ca in co c 00 $ $$ 0 E \z J k/53 IN q ]5a\ 42o/a )o N ;a } }3f) on co 0 up up o Ta in L- \ ) 00 CO CO scr CO ) UJ_ o Cai o co 0 WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0225 CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) a) d v d `0 0 0 a) G/ N O C E n N 0 d 2 4) N 0 E -c m P. 0 4, .0 u v E 0 E C O u_ n r nn 3 0 a) C U Q C t d a L a m .o s CU O N `0 L E E X E v x a 0 u FO v a c O u a) J c v u c m v a O O. 10 L en i2: Total Hours Billed O C0. F- Phone Number Your Agency's Contact Person: Household Number: SECTION II (To be completed by client) • 'a C 2 O m 4) 0 C o ;. t C 3 12 u w 4-7 CO N 4- LLO 0 NN U L d � L d0 Y C L14 L m N to y L �n - > RI A U) O YJ 10- s • u S t L N • Q v a m V1 3 c m O v C E L j m a r � v a _ cC N o0 v .N Number of Hours of Service Provided Hours of Service (Ex. 1:00 — 2:30) w I0 PY-13-14-CORE-0198 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND FAMILY MATTERS OF COLORADO, LLC This Agreement, made and entered into the day of , 2013, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Family Matters of Colorado, LLC, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Life Skills (Visitation, Parenting Skills); and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria 1 PY-13-14-CORE-0198 established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. 2 PY-13-14-CORE-0198. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and the Equal Pay Act of 1963; and the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals:\ i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 3 PY-13-14-CORE-0198 d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. 4 PY-13-14-CORE-0198 Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PL and PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training 5 PY-13-14-CORE-0198 CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. 6 PY-13-14-CORE-0198 c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Belinda McKenna Name 17. Notice Administrator Title Owner/Therapist Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Belinda McKenna, Owner/Therapist 712 2o° Street Fort Lupton, CO 80621 1970)576-2906 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0198 19. Termination This Agreement may be terminated at any time by either party giving thirty (3) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0198 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: if an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PV -13 -14 -CORE -0198 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0198 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board APP Co f.'"y Attorney WELD COUNTY DEPARTMENT OF HUMANS. RVICES By: 11 BOARD OF COUNTY'CO� COMMISSIONERS WELD COUNTr, ttyt�mHDO William F. Garcia, Chair CONTRACTOR: By: JUL 2 2 2013 Contractor ©w ` t Ti O;iv/,3 -/8Z PY-13-14-CORE-0198 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide in -office and in -home Life Skills services to individuals and families referred by the Department. In office visitation services will be provided at 712 2"d Street, in Fort Lupton, Colorado, or 1120 38th Avenue, Greeley, Colorado. 2. CONTRACTOR utilizes therapy models that include, but are not limited to, Structural, Integrated, Solution - Focused, and Cognitive Behavioral, as well as the Satir Communication Model. 3. Services include the following: a. Safe Exchanges —Supervised exchange of children for the purposes of parenting time where each parent or guardian shall have pick up and drop off times that will prevent face-to-face contact between the parties. b. Monitored/Supervised Visitation —Supervision of family visits, both verbally and physically, for positive and appropriate interactions. The supervising staff member shall be within sight and sound of all participants at all times and will intervene on a limited basis as necessary to ensure the safety and supervision of the child(ren). Supervision of family visits that include a competency -based nurturing program to meet the assessed needs of families. The supervising staff member will provide coaching and skills training to parents. Parents are then given the opportunity to practice new skills during visitation time. Emphasis will be placed on families completing the areas of greatest need first and progressing through the program accordingly. c. Therapeutic Visitation - An enhanced supervised visitation program that incorporates concepts from a variety of therapeutic disciplines such as individual, couples and family therapy, parent - child interactional therapy and parenting skills education. This blended approach is utilized to develop individualized interventions for the family. d. Parent Coach (In -home) — In -home support/coaching to teach parenting and household management skills in order for parents to become better caregivers for their children. Skills taught can include, but are not limited to, physical care of children, child development, discipline, nurturing, nutrition, relationships, budgeting, educational, medical, and safety. 4. All services will be provided by Belinda McKenna, MA, NCC, LPC. 5. CONTRACTOR can provide transportation when needed. 6. CONTRACTOR will ensure that all contact between the parent and the child is structured to provide for the safety and well-being of the children, and allows the parents the opportunity to learn and practice positive parenting, while maintaining the continuity of family relationships. 7. CONTRACTOR will continually assess parents regarding their capacity to appropriately care for their children. 8. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 12 PY-13-14-CORE-0198 9. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 10. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 11. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 12. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 13. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 13 PY-13-14-CORE-0198 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $45.00/Hour (Safe Exchange -In Office) $75.00/Hour (Safe Exchange, Out -of -Office) $75.00/Hour (Monitored/Supervised Visitation - In Office) $105.00/Hour (Monitored/Supervised Visitation, In Home) $110.00/Hour (Therapeutic Visitation, In Office) $140.00/Hour (Therapeutic Visitation, In Home) $140.00/Hour (Parenting Skills) $110.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred, Failure to submit by the aforementioned deadline may result in forfeiture of payment. 14 PY-13-14-CORE-0198 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 15 PY-13-14-CORE-0198 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 16 PY-13-14-CORE-0198 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-13-14-CORE-0198 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 18 PV -13 -14 -CORE -0198 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7'h of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-13-14-CORE-0198 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR.) TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 20 PY-13-14-CORE-0198 re 0 ✓ U K z Z 0 U 0 F F z W y W m J -J 0 Z a J W X W co ce u O (n in a u) NF o L N s Q 9 O £ J 3 W O . -:J a 5 a) oQ 0 its m L U_ c 2 0 2 n 2 O3 tri m N v J X W d Q ® E N 0 0 a`0 a{.A.p. �'ti }�� $'�• Ii y� ``iyl �" '₹"` •4'i � t � i i �3'�rt�?. y3r { ��s. i y .� �� { 3�v'�S� '�i ��'r�:t 8i,; { �� i `. ' r. LO N Y4zr Actual Household Approved Approved Hours Number Start End Date Date(s) or Units Client Name (Per Trails Case ID (Per Date (Per (Per of /Service Referral) (Per referral) referral) referral) referral) Service Period 12 vm„ 0 0 0 CO 0 'n„°=ova•+' 0 N 0 ao m 2; O co N; O 555555 viur•�. yti�u95 vri rye^{ifi v�+33 A�3ipu ` 1654888 SAMPLE ENTRY: Doe, John ti{i'rfiy�5 ti N WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0198 CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR.) Total Hours Billed 01 c CO a a r - u a E O C C E ° u L N C U J U,U, 'O b 461 Ul N za, 41 p N 0- 2 a a " a a1 � - Y Q ja ea v C D E u 0 O r 1U • N K U/ O C Z Section I: (To be completed by the CONTRACTOR) Primary Client billed: Phone Number Your Agency's Contact Person: Household Number: SECTION II (To be completed by client) Your signature verifies that services were provided by the service CONTRACTOR for direct face-to-face contact only, for the h O E c> R CC O L C u 0 m o ° CJ C v U n M Z .o Client/Participant Signature (Please have all those attending sign. In the case of a child who is not able to sign, please have someone sign for the child; i.e., Sally Smith by Gregg Jones, Foster Parent) Number of Hours of Service Provided Hours of Service (Ex. 1:00 — 2:30) 0 O E m Y 0 .e a a u: N E d E CO a. `° N: N a. OD C 0 a C E .o° 'U 3 c a OS E w O O U Q 3 K NH 2 C C E Z ra 1`5 PY-13-14-CORE-0197 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND FAMILY MATTERS OF COLORADO, LLC This Agreement, made and entered into the day of , 2013, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Family Matters of Colorado, LLC, hereinafter referred to as the "Contractor". WITNESS ETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria 1 poi -`876 PY-13-14-CORE-0197 established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. 2 PY-13-14-CORE-0197 • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals:\ i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 3 PY-13-14-CORE-0197 d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents, warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress overtime. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. 4 PY-13-14-CORE-0197 Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PL and PD) (Minimum). o Combined single limit -$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training 5 PY-13-14-CORE-0197 CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. 6 PY-13-14-CORE-0197 c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Belinda McKenna Name 17. Notice Administrator Title Owner/Therapist Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970)352-1551 18. Litigation For Contractor: Belinda McKenna Owner/Therapist 712 2nd Street Fort Lupton, CO 80621 (970) 576-2906 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0197 19. Termination This Agreement may be terminated at any time by either party giving thirty (3) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0197 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. 9 PY-13-14-CORE-0197 CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0197 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board By: ty Attorney WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 11 BOARD OF COUNTY COMMISSIONERS WELD COUN ,•LORADO CI J Garcia, Chair JUL 2 2 2013 CONTRACTOR: By: Contractor Dec Title DVS' -AM, '9 PY-13-14-CORE-O197 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide in -office and in -home Mental Health Services to individuals and families referred by the Department. In office services can be provided at 712 2"d Street, in Fort Lupton, Colorado, or 1120 38th Avenue, Greeley, Colorado. 2. CONTRACTOR utilizes therapy models that include Solution Focused, Narrative, Structural, Cognitive Behavioral, as well as the Satir Communication Model. 3. Services include the following: a. Individual Therapy —Services are available for adults and adolescents and are designed to address a wide variety of issues that impact the individual and family. The goal of the service is to remove any barriers to safety and well being in the home which may include, but are not limited to, behavior problems, depression, anxiety, stress, trauma, grief and loss, health, self- image, character and treatment compliance. b. Family Therapy — Services are available to families to address communication, togetherness, flexibility, family structure, family lifecycle, and multi -generational issues. Family interactions and resiliencies also are assessed and treated. 4. All services will be provided by Master's, or higher, level therapists. 5. CONTRACTOR can provide transportation when needed. 6. CONTRACTOR will ensure that all contact between the parent and the child is structured to provide for the safety and well-being of the children, and allows the parents the opportunity to learn and practice positive parenting, while maintaining the continuity of family relationships. 7. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 8. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 9. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 10. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 12 PY-13-14-CORE-0197 11. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 12. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 13 PY-13-14-CORE-0197 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $110.00/Hour (Therapy - Individual or Family - In Office) $140.00/Hour (Therapy - Individual or family - In Home ) $110.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. 14 PY-13-14-CORE-0197 b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 15 PY-13-14-CORE-0197 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 16 PY-13-14-CORE-0197 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-13-14-CORE-0197 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy) each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 18 PY-13-14-CORE-0197 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-13-14-CORE-0197 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR.) TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 20 PY-13-14-CORE-0197 \ 0 0 0 ID CO UJ 2 j f 2 } .2 )[/ k/\ TS• z " .E § )( )/\ To ca eD \ ■2 2 0 / §\% 2,300 0-3 {3A{ 5 LO LO 1.0 LO LO LO 0 \) CO ± Eo c fl 6 /!$a WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0197 CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR.) Ca C O a a �u a T) 0., i U -D C ~ m o. u u poi m Ili in ✓ N o• , Z Section I: (To be completed by the CONTRACTOR) Total Hours Billed Primary Client billed: Phone Numb Your Agency's Contact Person: Your signature verifies that services were provided by the service CONTRACTOR for direct face-to-face contact only, for the o a E Signature (Please ha O O : t C 3 v a s I- U 4) m u, o o o LL � N ra f° CUc u O W -000 00 C N C h0 _? 01 00 L C E C V) co y ? co 0.1 O N L Y O � S U t 00 N 0) O 01 E 0 in c > o . 2 •V L H f0 f6 a a? ▪ O- a (77.- Number of Hours of Hours of Servi Service Provided 0 O W 0) 0 y of the month follow All requests for pay' PY-13-14-CORE-0139 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND GREELEY COUNSELING CENTER This Agreement, made and entered into the day of , 2013, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Greeley Counseling Center, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 0/3ri?; PY-13-14-CORE-0139 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and 2 PY-13-14-CORE-0139 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. sea, and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE-0139 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its 4 PY-13-14-CORE-0139 subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PL and PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE-0139 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. 6 PV -13 -14 -CORE -0139 c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: lack J. Gardner Name 17. Notice Administrator Title Psychologist Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Jack J. Gardner, Psy.D. 1228 8th Street Greeley, CO 80631 (970) 356-8482 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0139 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0139 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage. Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-13-14-CORE-0139 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0139 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: • Weld County Clerk to the Board By: Deputy Clerk t•' e Board APP WELD COUNTY DEPARTMENT OF HUMAN ERVICES By: my Attorney 11 BOARD OF COUNTY COMMISSIONERS WELT CO LORADO am F. " arcia, CONTRACTOR: By: JUL 2 2 2013 �/-/J'26 PY-13-14-CORE-0139 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide evaluation, therapy and crisis intervention therapy services to individuals and families referred by the Department. Services include the following: a. Psychological Evaluations (Adult or Adolescent) —Evaluations utilize a multimodal approach specific to the client's needs using a variety of standardized personality tests (i.e., MMPI, MCMI), intelligence tests (i.e., WAIS-Ill, GAMA), substance abuse screens (i.e., urine or saliva samples), non -standardized tools (i.e., Life History Questionnaire, Children's History Questionnaire), clinical interviews, mental status examination, and review of collateral references. b. Parental Fitness Evaluations — Evaluations utilize a structured interview and rating scale to be completed by the examiner and the caseworker supervisor. The caseworker observes the interview and completes a rating scale. The interview utilizes a "job testing" assessment approach to help determine a parent's knowledge, skills, motivation, and capacity to effectively parent. c. Interactional Evaluations — Evaluation utilizes observation of parents and children to determine parenting capacities, strengths, needs, and attachment. d. Individual/Family Therapy —Therapy services are provided to address specific identified areas of trauma and/or conflict with individuals, families, couples and/or children. A combination of insight oriented therapy techniques with behavioral objectives is applied on a situation -specific basis. e. Crisis Intervention Services — Therapy services for adults, and/or children to address specific urgent situations. Crisis intervention techniques with behavioral objectives are applied on a situation -specific basis. f. Consultation — Consultation is available on a case -specific basis and is available to clarify treatment needs, diagnosis and prognosis, and better understand client needs. If requested, a brief report will be produced. 2. Services will only be provided by Jack J. Gardner, Psy.D. 3. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 4. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 5. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 6. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 12 PY-13-14-CORE-0139 7. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 8. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 13 PY-13-14-CORE-0139 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. in the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $1,470.00/Episode (Psychological Evaluation, Adult or Adolescent - In -office) $1,780.00/Episode (Psychological Evaluation, Adult or Adolescent - Out -of -office) $1,000.00/Episode (Parental Fitness Evaluation) $183.75/Hour (Partial Evaluation Hourly Charge - Not to exceed cost of complete evaluation) $168.00/Hour (Interactional Evaluation) $160.00/Hour (Crisis Intervention Services) $140.00/Hour (Case Consultation) $120.00/Hour (Therapy - Individual, Family) $120.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. 14 PY-13-14-CORE-0139 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 15 PY-13-14-CORE-0139 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 16 PY-13-14-CORE-0139 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-13-14-CORE-0139 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 18 PY-13-14-CORE-0139 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7`h of the month following the month of service in order to be processed for payment that month. Billing received after the 7`h of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-13-14-CORE-0139 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR.) TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month / Year: Charges: $ _ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 20 PY-13-14-CORE-0139 \ . §)k z \} 0'- 0r mom/ -0000X(04( t/)6=!t/ 7 @-2;@/7// 2/0 IQCsa O O O / § / 0 ( \ CC )§ CO tED ID CD ir 00 ){\ f\3 -O a)ao \ //\ o 'Co Lifeskills, Mental Health, k 2 O =o= 03 J k) 0D LO 23 |])a ) *o&! CD CD §) 7 Daft Ca 01) O to CO CO \ o <0 O WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0139 CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) Section I: (To be completed by the CONTRACTOR) Total Hours Billed lv I- Primary Client billed: N .O z N a a Your Agency's Contact Person: Household Number: SECTION II (To be completed by client) Your signature verifies that services were provided by the service CONTRACTOR for direct face-to-face contact only, for the Client/Participant Signature (Please have alt those attending sign. In the case of a child who is not able to sign, please have someone sign for the child; i.e., Sally Smith by Gregg Jones, Foster Parent) Number of Hours of Service Provided Hours of Service (Ex. 1:00 - 2:30) . 00 m r3 fa O 0 C 0 E N L O r0 1. d c 0 a E C C ryE a 4 c 0 0 S c E L C GI 3 .C c E a r CN pG 3 � O V « « O u E rp d PY-13-14-CORE-0215 Pill CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND LEAHY NEUROFEEDBACK CENTER, LLC This Agreement, made and entered into the cys day of JCL h C , 2013, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Leahy Neurofeedback Center, LLC, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services (Neurofeedback); and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 PY-13-14-CORE-0215 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and 2 Aw PY-13-14-CORE-0215 All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.5.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. H. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Hi. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE-0215 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE-0215 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PL and PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE-0215 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. 6 PY-13-14-CORE-0215 c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Susan Leahy Name 17. Notice Administrator Title Owner Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970)352-1551 18. Litigation For Contractor: Susan Leahy, Owner 6640 South Yukon Way Littleton, CO 80123 (303) 862-6863 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 k PY-13-14-CORE-0215 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0215 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-13-14-CORE-0215 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0215 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board By: A C attorney WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 11 BOARD OF CO LTY COMMISSIONERS WELD COUNTY, CoL'' ADO am F. Garcia, Chair CONTRACTOR: By: JUL 2 2 2013 /kr441-.t Contractor Title PY-13-14-CORE-O215 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Neurofeedback Training to foster children referred by the Department. 2. Services will occur at the Parent Education Center, a leased facility of the Department, in Greeley, CO, or at CONTRACTOR'S office in Lakewood, CO 3. The Department will provide "office space", located in the Weld County Department of Human Services' Parent Education Center located at 710 North 11th Avenue, Greeley, Colorado, hereinafter referred as "the Premises", as follows: a. Department will provide one work space to the CONTRACTOR, as the Lessee, which will be located at the Premises. b. In consideration of leasing of the aforesaid, the parties covenant and agree as follow: i. The Department will charge no rent to the CONTRACTOR for use of the Premises; H. CONTRACTOR agrees to use ordinary care when using the Premises; Hi. CONTRACTOR may not sublet any part of the Premises; iv. CONTRACTOR may not use the Premises for any purpose other than conducting the business and duties under the Agreement; v. CONTRACTOR shall keep the Premises clean and in sanitary condition; vi. CONTRACTOR shall allow Human Services any reasonable hour of the day to enter into or upon the Premises. 4. Services will be provided by Susan Leahy, OMC Certified Neurotherapist. 5. Services will be provided by appointment only. CONTRACTOR will operate one day per week (Saturday), 8:30 a.m.-4:30 p.m., unless otherwise agreed to by the Department and Contractor. CONTRACTOR will notify the Department in advance of any breaks in service due to holidays or personal time off. 6. CONTRACTOR will give priority to clients referred by the Department but services will be made available to post -adoptive families and general public with Department and Contractor approval if space is available. 7. CONTRACTOR will accommodate up to twelve (12) clients per day, utilizing at least two (2) work stations for a maximum of seven (7) hours per day. CONTRACTOR is permitted a one -hour lunch break and may elect to use that time for private pay clients as approved by the Department. 8. CONTRACTOR will solely determine charges to be paid by the Department by the total number of clients served per day of service. The total number of clients will be calculated based on the number of clients, both Department referrals and private pay, who complete services on any one day. 9. CONTRACTOR will only request reimbursement from the Department for those clients referred by the Department and authorized under Department funding as evidenced by an authorized referral form. 10. CONTRACTOR is solely responsible for collecting fees from private pay clients. For the purposes of this agreement, "private pay" clients are defined as clients not referred by the Department or authorized under Department funding. The Department will not be held liable for Contractor's inability to collect fees and such inability will not impact or change charges to the Department. 11. CONTRACTOR will provide scheduling by phone. CONTRACTOR will provide the Department a final schedule following each day of service that shows all clients scheduled for services and the status of their services for that day; "Completed" or "Failed to Attend". 12 PY-13-14-CORE-0215 12. CONTRACTOR will make at least three (3) attempts to contact caregiver for the referred client and set up services. The first attempt will occur within 72 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 13. CONTRACTOR will conduct a phone conference with the referring caseworker and caregiver prior to the start of any new referral when possible. If a referral arrives within the same week as the client's first appointment, contact with the caseworker and/or caregiver may occur the day of the first appointment or following the first appointment. 14. CONTRACTOR will assess each referred client prior to the start of Neurofeedback training utilizing the "CLIK" Test. The test measures an individual's continuous performance under low versus high demand "tasks". For purposes of the Neurofeedback training, it will provide an objective measurement to establish client baseline performance. CONTRACTOR will reassess each client at the conclusion of training (usually after approximately 20 sessions). 15. CONTRACTOR will require the caseworker and/or foster parent to complete a Symptom Behavior Checklist weekly for each referred client. The checklist utilizes a Likert scale and takes approximately three minutes to complete. Additionally, a brief list will be provided to the caregiver for daily completion between sessions. 16. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 17. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 18. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 19. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 20. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 13 PY-13-14-CORE-0215 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2013, and shall not exceed $400.00 per day. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $100.00/Session/Client (4 Clients/Day) $80.00/Session/Client (5 Clients/Day) $66.67/Session/Client (6 Clients/Day) $57.14/Session/Client (7 Clients/Day) $50.00/Session/Client (8 Clients/Day) $44.44/Session/Client (9 Clients/Day) $40.00/Session/Client (10 Clients/Day-Greeley or per sessions/client-Lakewood) $36.36/Session/Client (11 Clients/Day) $33.33/Session/Client (12 Clients/Day) $35.00/Episode (QIK Test $60.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. 14 PY-13-14-CORE-0215 CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 15 PY-13-14-CORE-0215 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). CONTRACTORs must specifically document efforts to engagefamilies in services and to control for safety. 16 PV -13 -14 -CORE -0215 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-13-14-CORE-0215 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 18 PY-13-14-CORE-0215 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-13-14-CORE-0215 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: / t kt f/ Billing Contact: /J -%" Address: 410O4 S. Phone Number: "it/con &LI 4irj/eivn,Co goo/z3 Description of Services (Program Area): MCP✓TAL 1464 i-i t1 *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAMAAAAAAAAAAAAAAAAAAAAAAAAAAAAMM FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 20 PY-13-14-CORE-0215 air Y O Q N U .. mtO O U D i Z m C ft 0 ® L N 03 Urcn c7c0 N N 9.'j F) (O (O CD •• 0= C 0 7 r N co I— ice o (n % u v 2-9 ) c m aim co E U) > a m -coo no.- m E 0 m n r (l)-, (J (0510-O2..." 2-3 0 H U I- H Z 0 a O H H Z w U) w 00 - J Z -J W U X w Z co N ce u) 0 2 0 ( E W N H i Li = Q E } O m J Z o w W p "' J (� 0 a cc C2, O (0 d t L -Co O ❑ m a) Cu C U) Cal N J W N w Q N Em m c mo o a 110 For Use By Human Services Only Comments Monthly Total (Calculates automatically) 0 o M 0 P (') N O ... CTS ao W at D N y 8 _ 11 N 0 W QI `o&a CA N CV N m U N Ws a) ❑ O (A 06/01, 06/02 TOTALS (Calculate Automatically) Approved End Date (Per referral) o) O O N 0 C) 0 Approved Start Date (Per referral) CD 0 0 N CD Household Number (Per referral) 555555 Trails Case ID (Per referral) _ 03 CO d' 4J CD Client Name (Per Referral) SAMPLE ENTRY: Doe, John ti N WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0215 CONTRACTED SERVICES CLIENT VERIFICATION FORM z Ol O VI 0 O OJ O O o 3 E '• `a v a m c o r C C U/ E N w to ▪ f0 a - 8 W O u 2 II o E O c•c O t i N O G a v E E O N E • o c c o IS E •y a1 V _ w CU .• L v m u w ✓ r -O ao y 2 m Ul �p N �1 0- C m O. U 0 - to T G -O v • a O E v 8 so ,43 Qt O z � Section I: (To be completed by the CONTRACTOR) Total Hours Billed Primary Client billed: Phone Number Your Agency's Contact Person: Household Number: SECTION II (To be completed by client) Client/Participant Signature (Please have all those attending sign. In the case of a child who is not able to sign, please have someone sign for the child; i.e., Sally Smith by Gregg Jones, Foster Parent) Number of Hours of Service Provided Hours of Service (Ex. 1:00 — 2:30) a) 0 C 0 O L 0 E 41 L O O 9 4• r .O u 41 E C d a .O Vl of m c 0 m L E a G L C .0 L 0 ap 0 *45 E 0 T+ A C ar A u fC 0 V 6 y O o 4.1 L ▪ O u E u W z r N N PY-13-14-CORE-0141 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND BARRY R. LINDSTROM, PH.D., LLC This Agreement, made and entered into the ' day of J 1Y' 013, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Barry R. Lindstrom, Ph.D., LLC, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013 upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with ail aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 PY-13-14-CORE-0141 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and 2 PY-13-14-CORE-0141 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. U. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE-0141 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 847.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE-0141 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. General Liability (PL and PD) (Minimum). o Combined single limit -$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE-0141 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 6 PY-13-14-CORE-0141 b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Barry R. Lindstrom Name 17. Notice Administrator Title Psychologist Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Barry R. Lindstrom, Ph.D. 3211 20th Street, Suite D Greeley CO 80634 (970) 356-3100 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0141 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0141 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-13-14-CORE-0141 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0141 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: Weld County Clerk to the Board By: Deputy Clerk to e Board BOARD OF COUNTY COMMISSIONERS WELD CO LORADO ram F. Garcia, hair WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES By: 11 By: JUL 2 2 2013 Contractor Title SILL 4a 7 - &'/S -4,76 PY-13-14-CORE-0141 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Mental Health Services to individuals and/or families referred by the Department, at 3211 20th Street, Suite D, in Greeley, CO, unless otherwise arranged. Services include the following: a. Mental Health Assessments/Psychological Evaluations —Assessments/Evaluations include an individual clinical interview to obtain relevant psychosocial history and mental status evaluation with each referred family members, conjoint clinical interviews with all family members (when applicable), conjoint clinical interview with child and current caregiver(s) if child is in out -of -home placement at the time of the referral, and psychological screening and testing. For adults, screening and testing may include the Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for Post -Traumatic Stress Disorder (PTSD), Stressful Life Events Questionnaire, Ratter Incomplete Sentences, Mood Disorder Questionnaire, Adult Self -Report Scale (for ADHD), and other screening instruments as needed. These may include the Minnesota Multiphasic Personality Inventory -2 (MMPI-2), Million Clinical Multiaxial Inventory -Ill (MCMI-III), Wechsler Abbreviated Scale of Intelligence (WASI), Bender Gestalt Visual Motor Test (BGVMT); Thematic Apperception Test (TAT), Projective Drawings, and the Rorschach Test. For children and adolescents, screening and testing may include the Behavioral Assessment System for Children (BASC) standardized behavioral assessment for each child, completed by the child (as age appropriate), parents, foster parents and teachers; Stressful Life Events Questionnaire; other non - standardized behavioral assessment and developmental history forms completed by parents, foster parents, and teachers as clinically indicated; Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A); Milton Adolescent or Pre -Adolescent Clinical Inventory (MACI, M-PACI); Thematic Apperception Test (TAT) or Children's Apperception Test (CAT); Projective Drawings; and the Rorschach Test. As clinically appropriate, evaluations will include consultation with collateral contacts, review of case records, previous evaluations and treatment records. b. Family (Interactional) Evaluations - Evaluate the child, the caregiver and the interaction between them across two or more sessions. Family evaluations require an average of eight (8) hours of direct contact and include the equivalent of an individual Mental Health Assessment of each family member and assessment of interaction between family members. Evaluations will assess risk factors from the Kempe Family Stress Inventory including: Parent Beaten or Deprived as a Child; Parent has a History of a Criminal Record, Mental Illness or Substance Abuse; Parent Suspected of Abuse in the Past; Parent with Isolation, Low Self Esteem or Depression; Multiple Stresses or Crises; Violent Temper Outbursts; Rigid, Unrealistic Expectations of the Child's Behavior; Harsh Punishment of Child; Child Difficult or Provocative or Perceived to be by Parent; and Child Unwanted or at Risk for Poor Bonding/Attachment Difficulties. Family Evaluations can also assess level and intensity of visitation and address issues related to visitation between children and incarcerated parents. The evaluation will include some or all of the following depending on family composition, child's placement and the caseworker's referral questions, and take from one to three months to complete: i. Interviews: a. Individual Clinical Interview(s) with each family member (1 to 2 hours for each member); b. Conjoint clinical interviews with all family members (including marital, parent -child, and sibling subsystems as clinically indicated; 3 to 5 hours) 12 PY-13-14-CORE-0141 c. Conjoint clinical interview / consultation with child and current caregivers (foster parent, relative etc) if child is in out of home placement at the time of evaluation. ii. Psychological Testing: a. Adults: Millon Clinical Multiaxial Inventory -III (MCMI-III), Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for PTSD, and Stressful Life Events Questionnaire (and others as clinically indicated) for each adult. [Additional psychological testing (see complete list above) can be completed as needed to address additional referral questions related to individual psychological functioning]; b. Children and Adolescents: Behavioral Assessment System for Children (BASC) standardized behavioral assessment for each child, completed by the child (as age appropriate), parents, foster parents, and teachers. Other non - standardized behavioral assessment and developmental history forms completed by parents, foster parents, and teachers as clinically indicated. iii. Evaluation Reports: A written report for all assessments/evaluations will be provided to the referring caseworker within thirty (30) days of the completion of the evaluation. This report will summarize the referral questions; brief case history; evaluation course; methods and procedures (including psychological testing, records reviewed and collateral contacts); findings; conclusions and recommendations. Evaluation reports will address both strengths and protective factors and risk factors or problems. Recommendations will focus on how to maintain the child in his current placement, or how a change in placement would help to move the child closer to his permanency goal. If the child is legally free for adoption, recommendations will include whether the goal of adoption is appropriate at that time and / or how to move toward getting the child into an adoptive home, and what type of home would best meet the child's needs. iv. Client Feedback: Individuals and families will be offered a final diagnostic feedback session as part of the evaluation process to discuss test results and the findings and recommendations of the evaluation. Copies of the evaluation will be distributed to appropriate parties by the caseworker or psychologist in keeping with privacy laws, client consent and legal and professional standards. a. Individual and Family Treatment Services —Services will be problem -focused and will assist in the resolution of the issues that led to the Department's involvement with the family, as well as supporting the treatment goals of safety, well being and maintenance of the child's placement. Treatment will include development, cognitive -behavioral and family systems approaches with an emphasis on a continuum of care and evidence -based practices. 2. Services will be provided by Barry R. Lindstrom, Ph.D., and Bonnie S. Lindstrom, M.S, LPC. All Mental Health Assessments and evaluations will only be conducted by Barry R. Lindstrom, Ph.D. 13 PY-13-14-CORE-0141 3. CONTRACTOR will make at least three (3) attempts to contact the client and setup services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 4. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 5. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 6. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 7. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 8. CONTRACTOR may bill for participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TDM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length. All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 14 PY-13-14-CORE-0141 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $325.00/Hour (Evaluation) $125.00/Hour (Indivudal Therapy - Ph.D.) $65.00/Hour (Individual Therapy - M.S.) $150.00/Hour (Family Therapy - Ph.D.) $75.00/Hour (Family Therapy - M.S.) $150.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting/Case Consultation - Ph.D.) $75.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting - M.S.) $125.00/Hour (Clinical or Educational Staffing - Ph.D.) $75.00/Hour (Clinical or Educational Staffing - M.S.) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. 15 PY-13-14-CORE-0141 CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 16 PY-13-14-CORE-0141 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress overtime. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 17 PY-13-14-CORE-0141 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 18 PY-13-14-CORE-0141 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy) each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 19 PY-13-14-CORE-0141 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 76 of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 20 PY-13-14-CORE-0141 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Address: Billing Contact: Phone Number: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAMMAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: / _ Core & Service Contract Coordinator Date 21 PY-13-14-CORE-0141 ai a • O N U a) — I ) (v C E 0 r. Z N to c Q a) Il 0 O 0) a LC) C%1 N Tr; C-1 UQ) c)LU�CD .N 7.'E M CD 1.0 (0 X pU-? Na o0 N(0 � pflJ . JUU c 0 NM M + .0 7 o N 0 ` rn rn cn-)cn5za:091 LL 0 I- U f - z 0 U O H I- z W Co W m J J z J W U X w Z U a) n v 0 L -o E 1)) a) I — e. N U O • E >,CLZ DLO • ow O + -'J U a) a_ a For Use By Human Services Only Comments Monthly Total (Calculates automatically) o o o Co I I I I I - I 1 1 1 1 �1 1 • 1 1 . O o 0 co ai 45 o L c Ct a.2 0 D N co U iv F2 .E �C O az ova. N N -- t U a) 2 a ocn 06/01, 06/02 Approved End Date (Per referral) co 0 0 N C7 co CCD Approved Start Date (Per referral) o) 0 0 N 7 Cc) Household Number (Per referral) 555555_ Trails Case ID (Per referral) SAMPLE ENTRY: Doe, John 1654888 Client Name (Per Referral) WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0141 CONTRACTED SERVICES CLIENT VERIFICATION FORM N u m m 0 w 0 C 0 L N E a • 0. OJ O w N • L�+ C 01 E T N ry .� 0. O O L 7 a+ m ) 7 a O `1 N O al • N 0 u N Co h .0 • E E E ▪ m r E Y • v MI N E a O C 3 w w 01 N 0) d ▪ W w 0) n v v E L ▪ LL O 0 O O E N L • C ▪ O1 b0 V 7 • w c mo U '7, Z Y C v u Q 0. 0 0 0. m v O Q N CC C I— m Z 0- O V ✓ u ✓ N � N 0 0 z Section I: (To be completed by the CONTRACTOR) Total Hours Billed 0 Primary Client billed: Phone Number Your Agency's Contact Person: Household Number: SECTION 1I (To be completed by client) the service CONTRACTOR for direct face-to-face contact only, for the O y 44)`:, u N [C O 4) a bli d v O v C C) it C It 0 4) m C on t O 7 .v. } V CC C C .� v_ C3 -0 w c v v O C Number of Hours of Service Provided 0 C 0 0 L C 0 E .0 0 0 0.1 .0 .0 .0 i Li N 0 E C E O. w 0 i m C .0 0 cn D C 0 E N L 0 N E 0 Cu w Li a+ d u ft u Notice to CONTRACTOR: At the month of service. PY-13-14-CORE/CPS-0001 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND TRUTH CORPORATION DBA ACCOUNTABILITY POLYGRAPH SERVICES This Agreement, made and entered into the ( K "day of S4U'L-e 2013, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Truth Corporation DBA Accountability Polygraph Services, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Child Welfare Administration or Core Services funding to the Department for Polygraph Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013 upon proper execution of this Agreement and shall expire May 31, 2014 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Child Welfare Administration or Core Services funding during the duration of this Agreement. 1 07/9/S -/F7‘ PY-13-14-CORE/CPS-0001 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.• and 2 PY-13-14-CORE/CPS-0001 All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Child Welfare Administration or Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Hi. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE/CPS-0001 iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(6). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE/CPS-0001 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease, covering all employees at work site. General Liability (PL and PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE/CPS-0001 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 97D-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. 6 PY-13-14-CORE/CPS-0001 b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: Gale Page Name 17. Notice Administrator Title Owner Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Gale Page, Owner 68 Inverness Lane East, Suite 201 Englewood, CO 80112-5108 (303) 799-6688 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE/CPS-0001 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, director indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-13-14-CORE/CPS-0001 submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-13-14-CORE/CPS-0001 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE/CPS-0001 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: R OARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board By: Deputy Clerk to t ' Board By: WELD COUNTY DEPARTMENT OF HUMAN SERVICES 11 CO %'ADO F. Garcia, Chair JUL 2 2 2013 CONTRACTOR: 4tcouw4(aWE &y5ro.rk f'er c. s By: Contractor "re* Title a�/.�- i f.76 PY-13-14-CORE/CPS-0001 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Sexual Abuse Treatment Services in the form of Polygraph Services for youth engaged in offense -specific treatment through a program that does not include polygraphs, as referred by the Department. 2. If the youth is on Probation, the cost of each referred polygraph will alternate between Probation and the Department. 3. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any youth whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately. 4. CONTRACTOR will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 5. CONTRACTOR will submit a written report to the referring caseworker within two (2) weeks of completion of the service. 12 PY-13-14-CORE/CPS-OOO1 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $250.00/Polygraph (Sex History, Issue Specific, Maintenance) $100.00/Polygraph (Travel outside of the Denver area.) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 13 PY-13-14-CORE/CPS-0001 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 14 PY-13-14-CORE/CPS-0001 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. CONTRACTORS should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORS should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 15 PY-13-14-CORE/CPS-0001 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy) each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 16 PY-13-14-CORE/CPS-0001 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 17 PY-13-14-CORE/CPS-0001 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 18 PY-13-14-CORE/CPS-0001 W 0 I- U I' H z 0 U O H H Z W W J J a z J U X W (n Cl) a) CC .52 (n N J -o E D a) N N 2 Q E O . i Z LO • W o U '6' a_ -a _� a) asi < (o m 2 a) 2 ui N 9- J X LU @ a) Q a) E m co � � o o I a0 For Use By Human Services Only Comments Monthly Total (Calculates automatically) o O O O CO ;:: .. . • `300.00 L N 43 O L C 1 N w a) (6 i > o a) U O a) Q= `ova N N N N _ U +. O woo - <- N 0 0 ) TOTALS (Calculate Automatically) Approved End Date (Per referral) 8/30/2009 Approved Start Date (Per referral) W co co N 4.0 Household Number (Per referral) 555555 Trails Case ID (Per referral) CO CO CO O CD ,r. Client Name (Per Referral) SAMPLE ENTRY: Doe, John WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE/CPS-0001 CONTRACTED SERVICES CLIENT VERIFICATION FORM u O 01 d `0- -o0 O O w a E oh t f0 a m N w O a a E v N N L w � Q O m Z oh O } U L E w E E E x •n we E E X O w w O C O 3 E. v > N G a u Y a E E O t L. C u O O 0 O w •� C w w H J w L c L% W C V m w � 2 Y a O` w O. u U Section I: (To be completed by the CONTRACTOR) Total Hours Billed Primary Client billed: Phone Number Your Agency's Contact Person: C U S d 0. p W A w E a 3 O = Z w O O Client/Participant Signature (Please have all those attending sign. In the case of a child who is not able to sign, please have someone sign for the child; i.e., Sally Smith by Gregg Jones, Foster Parent) Number of Hours of Service Provided Hours of Service (Ex. 1:00 — 2:30) w 00 n AC G O E Lw r.� O >- 0.• w a N E C d E m a O C- U c a C a w c .c C E w .O 0 E O c O Oh OO au > C .c 1- u Q K w Z O o V L o w O z PY-13-14-CORE-0136 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND VICTOR H. CORDERO, PSY.D., P.C. This Agreem ent, made and entered into the day of , 2013, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Victor H. Cordaro, Psy,D., P.C., hereinafter referred to asthe "Contractor". W ITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree asfoflows: 1. Term This Agreement shall become effective on June 1. 2013, upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in corn pliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billine(Trackin¢ CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference; 4, Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding duringthe duration of this Agreement. &l2//" /J'77 PI -13 -14 -CORE -0136 a. CONTRACTOR shall submit an Itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of thisAgreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Departm ent by the 7th day of the m o nth followingt he month the cost was incurred. Failure to submit by the -aforementioned dead line may result in forfeiture of payment.. b. Payment pursuant to thisAgreem ent, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof, c. The Department shall not be billed for, and reimbursement shall not bemade for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreem ent. 5. Financial Management At all times from the effective date of Agi-eement until completion ofthisAg-eemant, CONTRACTOR shall comply with the administrative requirements, cost principles andother requirem ents set forth In the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Ag-eem ent must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreem ent, b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reportingrequirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including but not limited to the following a. Compliance with Applicable Laws At all times during the performance of thisAgreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledgesthat the following laws are -included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. sea, and its implementing regulation, 45 C.F.R. Part 80 et. la; and 2 PY-13-14-CORE-0136 • All provisions of Civil Rights Act of 1986 so that no person shall, on the wounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or he otherwise subjected to discrimination under the is approved Agreern ent, • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implem eating regulations, 45 C.F.R. Part 94; and • the Age Discrimination Act of 1975, 42 U.S.C, Sections 6101 et. al, and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, R.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National orign, and sex, religion and handicap, includingAcquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain accessto client records except as permitted by 42 C.F.R. Part 2, 45 C.F.R. Part 74, Appendix G 9, which requiresthat affirmative stepsbe taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and serrvices. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (CR,S.) 26-6-104, requiring crim inal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the know ledge that any person who feels that s/he has been discriminated against hasthe right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Hum an Services, Office for Ovil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds, c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period precedingthis Agreem ent, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining attemptingto obtain, or performing public (federal, state or local) transaction or contract under a public transaction; violation of federal or state antitrust statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-13-14-CORE-0136 iv. Have not, within a three-year period precedingthis Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (CR,S,) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under thisAgreem ent or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents, warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Pro gam administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to corn ply with any requirem ents of this provision or C R.S. 8-17,5-101, et. seq., the Department may terminate thisAg-eement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in CR.5. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to CRS. 24-76.5-103(4) if such individual appliesfor public benefits provided under this Agreem ent. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C,R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by CR,S, 24-76.5-103 prior to the effective date of this Agreement. 6. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's perform ance accordingto national standards and monitor progress over time. Followingthe review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under thisAgreemant to families and children referred by the Department will continually strive for positive outcom es in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit Cwhich will address the aforementioned three areas, unless otherwise determined by the Department. 9, Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or dam ages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this 4 PY-13-14-CORE-0136 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Corn missioners of Weld County, its employees and agents, shall be named as additional nam ed insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PLand PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or arty party to whom Department services are being pro vided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the tim a of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreem ent. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreem ent. 5 PY-13-14-CORE-0136 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training attending the training -or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the m onitoring and evaluation shall be provided to the Board of Weld County Comm issioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modificationsto this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold paym ent to Contractor until the necessary services or corrections in performance are satisfactorily completed. 6 PY-13-14-CORE-0136 b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstancescaused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Departm ent. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agi-eement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreem ent, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Departm ent: Heather Walker Name For Contractor: Victor H. Cordero Name 17. Notice Administrator Title Psvcholoeist Title All notices required to be even by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writinga substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Grieco, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: Victor H. Cordero, Psvcholoeist 2870 North Speer, #240 Denver, CO 80211 (303) 455-9480 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement, Contractor, within Five (5) calendar days after being served with a summons, complaint, or other pleading which has been Filed in any Federal or State court or administrative agency, shall deliver copies of such docurnent(s)to the Director of Human Services. The term "litigation" includes an assignor ent for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-013b 19. Termination This Agreement may be terminated at anytime by either party gyin gthirty (30) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part_ of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, asthisAgreem ent is subject to the availability of funding. Therefore, the Department may terminate this Agreem ent at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Departm ent. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating t o such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not Included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits underthisAgreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or Interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governm ental immunity Act §§24.-10-101 et seq., as applicable now or hereafter amended. 22. Partial invalidity of Aereem ent If any section, subsection, paragraph, sentence, clause, or phrase of this Ag-eem ent is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreem ent and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Im oroorieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Ag^eem ent or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of aronflict of interest, it is -not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that giv es the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of Interest situation, CONTRACTOR shall 8 PY-13-14-CORE-0136 submitto the Departm ent, a full disclosure statement setting fo rth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of itsAgreem ent with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an em ployee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agreesthat authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review throudi on -site visits, all activities related to thisAgreement, supported with funds under this Agreement to ansureco m pliance with the terms of this Agraem ent, Contracting parties a greEthat monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreem ent, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in aform identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirem ants before access to confidential data is permitted. CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. S PY-13-14-CORE-0136 26. Proprietary Information Proprietary information for the purposes of thisAgreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, butdoes not include information (1.) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerningthe other party obtained as a result of this Agreem ent. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreem ent will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become em ployees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreem ent shall he binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0136 IN WITNESS WHEREOF, the parties hereto have duty executed the Agreement as of the day, month, and year first above written, ATTEST: �',.�_ �► BOARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board By: Deputy Clerk to " e Board WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: y A. Grie; ■, Director CONTRACTOR: 11 By: LD OOUI\ T , O 'iRADO F. Garcia, Chair Title JUL 2 2 2013 Contractor 0W3'-/87 PY-13-14-CORE-0136 EXHIBIT A SCOPE OF SERVICES 1, CONTRACTOR will provide Mental Health Services to individuals and/or families in Weld County referred by the Department. Services include the following: a, Psychological Evaluation — Evaluation includes a comprehensive evaluation of the client utilizing various assessment tools including standardized, objective, projective and otherwise normed instructions, as well as questionnaires, mental status examination and dini cal interview. Testing and screeningmay include, but are not limited to, any of the folio winginstrum ents; Wechsler Intelligence Scale -III or subtests, Universal Nonverbal Intelligence Test, other tests of cognitive/intellectual ability, Wechsler Abbreviated Scale of Intelligence, various inform al cognitive/neuropsychological tasks, Minnesota Multiphasic Personality Inventory -II (MMPI-II), Personality Assessment Inventory (PAI), Milton Clinical Multiaxial Inventory -Ill (MCMI-III), Milton Adolescent Clinical Inventory (MAGI), Parenting Stress Index, Child Abuse Potential Inventory, Beck Scales of Depression and Anxiety, State Trait Anger Expression Inventory, Trauma Symptom Checklist for Children, and other screening/testing assessm ents. Face-to-face interview and testingtim a will range from five (5) to seven (7) hours, plus scoring interpretation, collateral contacts and report generation. b. Psychosexual Evaluation — Evaluation includes a comprehensive evaluation designed to provide clinical, psychosexual, risk assessment and other relevant information in addition to additional input as requested. Evaluation will provide useful response to specific referral questions and will be guided by the Sex Offender Management Board (5OMB) Standards and Guidelin es, with the interest of community safety being param ount. c. Interactional Evaluation — Evaluation of parent -child dynamics, family dynamics, capacity to parent and overall parent ability as determined by, but not limited to, in -person observation of the parent or family during visitation with the children, interview with the parent, parenting related questionnaires and collateral contacts. These evaluations can occur at scheduled visitation time at supervising agencies, the evaluator's office, or in the client's home. d. Mental Health Evaluation —Specific evaluation utilized to assess for the presence of specific mental, emotional, behavioral or psychological process. it is not a comprehensive evaluation of personality, global functioning or intellectual capacity. Assessment is completed utilizing screening instruments, sym ptom checklists, formal mental status examination, and clinical Interview, as well as psychological evaluation tools asappropriate. Face-to-face interview and testing will range from three (3) to five (5) hours, plus scoring collateral contacts and report generation. e. Individual and Family Counseling —Services to assist in identifying barriers to appropriate parenting. Interventions are designed to improve safety of children in the home, assist in stabilizingthe home environment and adult/caregiver behaviors, and intervene in order to affect m ore positive, healthy family dynamics and functioning. 2. Services will be provided by Victor H. Cordero, Psy,D, 12 PY-13-14-CORE-0136 3. CONTRACTOR is bi-lingual (Spanish/English). 4. CONTRACTOR will make at least three (3) attem ptsto contact the client and set up services. The first attempt will occur within 24 hours of receivingthe referral (excluding weekends and holidays). CONTRACTOR will document effortsto engage client in referred services. If after three (3) attem pts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator im m ediately. 5, CONTRACTOR will identify in detail areas of continued concern and make recom m en datio ns to the Department regarding continuation of services and/or the need for additional services. 6. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral, Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported Immediately AND on the required monthly report. 7. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. B. CONTRACTOR agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making(TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change infrequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 9. CONTRACTOR may bill for participation in Team Decision Making (TOM) meetings and Family Team Meetings (FTM), when approved by the Department prior to the TOM or FTM occurring, and when the TDM or FTM is a minimum of one (1) hour in length, All other staffings and/or meetings with Department staff are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 13 PY-13-14-CORE-0136 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department ag-ees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreem ent shall be reported by the Departm ent in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreem ent, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $800.00/Episode (Mental Health Assessment) $800.00/Episode (interactional Evaluation. One Parent/One Report.) $500.00/Episode (Additional Charge/Interactional Evaluation. Two Parent/One Report.) $1,200.00/Episode (Psychological or Psychosexual Evaluation) $350.00/Hour (Hourly rate for partially completed evaluations. Not too exceed the full cost of the evaluation.) $100.00/Session (Individual Therapy, 50 -Minute Session) $120.00/Session (Family Therapy, 50 -Minute Session) $120.00/Hour (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) CONTRACTOR may not attempt to collect co -pays and/or feesfor services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billingsto the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. 14 PY-13-14-CORE-0136 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreernent in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or -the test result. 15 PY-13-14-CORE-0136 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas Safety, Permanency and Well Being of families. For each outcome, data and performance indicators m easure each state's performance according to national standards and monitors progress overtime. Foil owingthe review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine If the systems necessary to achieve positive outcomesfor families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes In the areas of safety, permanency and well-beingfor our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports Include observations and recom m endations regarding cllentsin a way that specifically addresses the areas of safety, perm anency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Departm ent contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs ■ CONTRACTORs should always consider thefollowingdefinitions regarding child safety when assessing families. e Children are considered safe when there are no present dangers or impending danger threats or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect)for parenting behavior that is harmful and destructive to a child's cogaitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to Insure safety of the child(ren). ▪ CONTRACTORsmust specifically document efforts to engage fam i lies in services and to control for safety. 16 PY-13-14-CORE-0136 Permanency Outcom es CFSR Outcom e Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORS: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are workingtoward achievingthat goal. • CONTRACTOR reports must indicate progess toward achievingthe permanency goal and should make specific recommendationsregardinghow the continuation of the service may assist in achievingthe goal. • CONTRACTORs should continually provide recommendations about whether any out -of -horn e placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORS' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving perm anency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specifictimefram es when recomm ending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being2 Children receive appropriate services to meet their educational needs. Well Being] Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This m ust be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recom m endations regarding whether that CONTRACTOR's service continues to he appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional servicesthat may address these concerns *Standardized reports will be provided and should he utilized by all agencies providing ongoing services to the Department'sfamilies unless otherwise noted. 17 PY-13-14-CORE-0136 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed bythe Department. Failureto comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. Averbal or -written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through aTeam Decision Making (TDM) or Family Team Meeting (FfM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 18 PY-13-14-CORE-0136 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement)., and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Departrnent. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk VJCDHS/Service Utilization Unit Mailing Address: P.O. Box 1J Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, Co 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-12-13-CORE-0136 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core & Service Contract Coordinator Date 20 PY-12-13-CORE-0136 03 I \ $ -J w Coa < §& c \ t -O 0 For Usi-By Human Services Only Comments .. r a } ; % : r yK y. 'Monthly Total" (Calculates o- automatically) 300.00 . . :. G . . . . ° < \co . . 2 . k ibk 9 Ce O.I o= uo 3 E �®2a7 a = _ + '- / = o- a) 2 / \ 2 7 a)o$ 0owoo q \ 0 I TOTALS (Calculate Automatically) Approved End Date (Per referral) o / CO Household Approved Number Start (Per Date (Per referral) referral) 0) Q i 555555 Trails Case ID (Per referral) CO / Client Name (Per Referral) SAMPLE ENTRY: Doe, John WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-12-13-CORE-0136 CONTRACTED SERVICES CLIENT VERIFICATION FORM Section I: (To be completed by the CONTRACTOR) Total Hours Billed Primary Client billed: Phone Number Your Agency's Contact Person: Household Number: SECTION II (To be completed by client) w T C O C 0 U N V b CJ U H C H z 0 0 U C) o d O 0. i V .0 ti w .4) } ai U O E ✓ a .b E) C 0 O .0 0 d a C o >.. U O v U ▪ n o d � v � O O Zt se of a child who is not able t all those attending sign. In the a, C 4) ro 0. 4) N O LL 41 4) C O N C7 .a L co >- V1 ai L > U A a, .C 0 4) f6 O.. N 0. 4) N O C Q f4 41 C in C ▪ > O. 0 .O ▪ an co co 0. a) ▪ a v MCo U 'v7 Number of Hours of Service Provided Ca 0 rification fo Notice to CONTRACTOR: Attach all c the month of service. PY-13-14-CORE-0131 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND W. TROY HAUSE, ATTORNEY AT LAW This Agreement, made and entered into the day of , 2013, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and W. Troy Hause, Attorney at Law, hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Service has provided Core Services to the Department for Mediation Services; and NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2013 upon proper execution of this Agreement and shall expire May 31, 2014, unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s) eligible for child protection services in compliance with Exhibit A "Scope of Services," of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D "Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B "Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule" shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria 1 O7DXF -76996 PY-13-14-CORE-0131 established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7`h day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for, and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives, contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws, orders, and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, se, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the is approved Agreement. 2 PY-13-14-CORE-0131 • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and • the Age Discrimination Act of 1975, 42 U.S.C. Sections 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L. 99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin, and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, CONTRACTORS, and sub -contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not, within a three-year period preceding this Agreement, 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph 12 of this certification; and iv. Have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 3 PY-13-14-CORE-0131 d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents , warrants, and agrees that is (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement, CONTRACTOR must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is (a) is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. 24-76,5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. 4 PY-13-14-CORE-0131 Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteer, and agents engaged in the performance of the Agreement. Upon request, CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure, either personally or through its employer as applicable to the CONTRACTOR'S business, at its own expense, and maintain for the duration of the work, the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability o As required by State statute including occupational disease, covering all employees at work site. • General Liability (PL and PD) (Minimum). o Combined single limit - $500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below $500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability (Minimum) for any CONTRACTOR transporting children or any party to whom Department services are being provided. Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-13-14-CORE-0131 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215, x6503, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. CONTRACTOR shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by Contractor pursuant to the terms of this Agreement. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. All such monitoring shall be performed in a manner that will not unduly interfere with work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by Contractor. These remedial actions are as follows: a. Withhold payment to Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if 6 PY-13-14-CORE-0131 performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. c. Incorrect payment to Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s): For the Department: Heather Walker Name For Contractor: W. Troy Hause Name 17. Notice Administrator Title Attorney at Law Title All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 352-1551 18. Litigation For Contractor: W. Troy Hause, Attorney at Law 710 11th Avenue, Suite 205 Greeley, CO 80631 (970) 351-6711 CONTRACTOR shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 7 PY-13-14-CORE-0131 19. Termination This Agreement may be terminated at any time by either party giving thirty (3) days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of 8 PY-13-14-CORE-0131 interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with CONTRACTOR. CONTRACTOR certifies that federal appropriated funds have not been paid or will be paid, by or on behalf of CONTRACTOR, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records CONTRACTOR agrees that authorized local, federal, and state auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities "shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by CONTRACTOR, in a central location and shall be made available to Human Services upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records CONTRACTOR shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection, no information about or obtained from any applicant/recipient in possession of CONTRACTOR shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with CONTRACTOR's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. CONTRACTOR shall advise its employees, agents, and sub -contractor, if any, that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub -contractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. 9 PY-13-14-CORE-0131 CONTRACTOR shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by CONTRACTOR in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by CONTRACTOR for similar information in the course of its own business. 27. Independence of CONTRACTOR: Not Employee of Weld County CONTRACTOR agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of the execution of this Agreement. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as stated in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. CONTRACTOR or the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 10 PY-13-14-CORE-0131 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: • Weld County Clerk to the Board By: AP my Attorney Deputy Clerk to " e Board OARD OF C N COMMISSIONERS LD C• . RADO Iliam F. Garcia, Chair JUL 222013 WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES By: 11 By: Contractor AL -7 - Title PY-13-14-CORE-0131 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Mediation services to Weld County families in Dependency and Neglect cases as referred by the Department. 2. CONTRACTOR will attempt to facilitate resolution of issues between the parties, which will lessen the amount of Court time and contested matters, assist in providing permanency for children in a shorter time frame, and assist the parties in coming to their own resolutions which are more likely to be followed. 3. CONTRACTOR can facilitate up to six (6) mediations per month and can offer flexible meeting times to accommodate mediations including early morning, noon, evenings and weekends. 4. Mediation sessions are generally scheduled for one (1) to two (2) hours in length; however CONTRACTOR can accommodate longer sessions up to one (1) day in length under special circumstances. 5. CONTRACTOR employs a full-time legal assistant who schedules and prepares for mediation sessions on behalf of the CONTRACTOR. 6. All mediation services will be provided by W. Troy Hause, Attorney at Law. 7. CONTRACTOR will submit a statement that states whether or not agreement or partial agreement was reached for each referral. This statement will be submitted with each monthly billing. 12 PY-13-14-CORE-0131 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2014. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $200.00/Hour (Mediation Services) CONTRACTOR may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 13 PY-13-14-CORE-0131 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS (CFSR) The Child and Family Services Reviews (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review, a Performance Improvement Program (PIP) will be implemented for the state to enhance services to families. Additionally, the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area, the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being, followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are, first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats, or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect) for parenting behavior that is harmful and destructive to a child's cognitive, social, emotional and/or physical development, and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 14 PY-13-14-CORE-0131 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out -of -home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs' opinion. • CONTRACTORs should continually assess family relationships (parent/child, sibling/sibling, extended family/child, etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well -Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 15 PY-13-14-CORE-0131 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all contractors regardless of the service being provided, unless otherwise directed by the Department. Failure to comply with these procedures may result in delay of payment or denial of billed charges. Referral: 1) Authorized referrals are forwarded to contractors via e-mail. 2) Once received, carefully review the referral for service information, client contact information and specific information regarding the start and end date of the referral. a. Services provided prior to the start date or after the end date of an authorized referral will be not be reimbursed. Services SHOULD NOT begin prior to having an authorized referral. b. A verbal or written authorization from a caseworker or supervisor does not constitute an authorized referral. If contacted by a caseworker or supervisor to start a service please contact the Child Welfare Contract and Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home -based, etc.) are reviewed by the Department periodically. Contractors are asked to provide input regarding client status/progress. You will be notified in advance via e-mail if you have case up for review. Contractors may attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Child Welfare Contract and Services Coordinator, through a Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A verbal or written authorization from a caseworker or supervisor does not constitute authorization to modify a referral. If contacted by a caseworker or supervisor to modify a referral please contact the Child Welfare Contract and Services Coordinator for a referral. Tracking: 1) Each client receiving face-to-face services must sign a Client Verification Form at the time of service regardless of the service being provided unless otherwise directed by the Department. 2) If multiple clients are receiving services together (ex. Family therapy), each member should sign the same form at the time of service. 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 16 PY-13-14-CORE-0131 4) If a child is receiving services and is unable to sign, then an appropriate person should sign for the child and indicate their relationship to the child (ex. Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7`h of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures, and 4) a monthly progress report if applicable submitted per the online format required by the Department unless otherwise directed by the Department. A contractor also may include their own invoice or other documents they feel are applicable. a. Monthly progress reports will be distributed to the appropriate caseworker once the billing is processed. b. Billing documents must be submitted with ORIGINAL SIGNATURES. Faxed copies of the Authorization for Contractual Services or Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: Joceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North 11th Avenue, Greeley, CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 17 PY-13-14-CORE-0131 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Address: Billing Contact: Phone Number: Description of Services (Program Area): *Service Month / Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: / Core & Service Contract Coordinator Date 18 PY-13-14-CORE-0131 o Q N .6 L N U N r- to E ' co z>01 en n, < a) w. N a Q LULU 2 Z+'E. C9 (O LU CO F-- p CO X aC) C m N ix)" M z U 75= O N i r— C O }— U F- z O 0 O I- I- z w w m J J_ 0 z J W U X w z_ co U a� c U_ O u_ c) N E .(1 12 �U Q O. } Z k -O w o o1 - a) a)'GTa a� 2 C a) Y LO X W W o E 2-3 c cn 0 0 o EL For Use By Human Services Only Comments Monthly Total (Calculates automatically) o O 0 o Mc.. M I I I I I I 1 ._ 1 1 1 1 1 1. 1 p 0 ) CCQ2o2 +N. 0 73r (6 N .c 5 0 3 D ._ <Io Q) Q. N -- U a) Ili a) 0 0 O) 06/01, 06/02 TOTALS (Calculate, Automatically) Approved End Date (Per referral) 8/30/2009 Approved Start Date (Per referral) O) O O N up Household Number (Per referral) (n to u) LU LU Trails Case ID (Per referral) co Co co v LU co T Client Name (Per Referral) SAMPLE ENTRY: Doe, John WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0131 CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) u H •O a) O 0 C O a, .0 C E w u E. v a�i 6 c y C a E % •N o O Y � W N D C v, a v al O u '^ t E E E F Y •O 61 u axi C C O C M V N w a) a u N L w w a) c E E O >. CL 1a E o •r LL 0 0 O C E a) u E j al t C C• C 1.1 0 co C O °° v a) N Z v .r-2 O. C O a O. u O. ra Q Total Hours Billed Phone Number Your Agency's Contact Person: Household Number: cY 0 U O U a, C, v 0 v a, V C) N a, e CTO 1-4 ai V O C .r A C a, .O O c a � V E u .O 2 to aal 0A a) y E O 8 . V 0 .O V n Z .� O as C, P.' a VI Z a) .O 1.4 O C N O Y L C 3 � -0 a] o_ s u a) tnn 0 O Li - r]) N '^ v m u a) 0.0 t pp C al m >- 0 -O as LC C Y CO 0 01 o ai L Y 0 a7 > �C t a) N `o a) a) C N L C 7 C A O O1 CCO E C a) f0ra yO. L (41 ` N NO. C C C Qa V 'N Number of Hours of Service Provided Hours of Servic (Ex. 1:00 — 2:30) 0 Notice to CONTRACTOR the month of service. Hello