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Home My WebLink About20132827.tiffRESOLUTION RE: APPROVE TWO (2) CHILD PROTECTION AGREEMENTS FOR SERVICES AND AUTHORIZE CHAIR TO SIGN - TENNYSON CENTER FOR CHILDREN AND SHILOH HOME, INC. 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 two (2) 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 Tennyson Center for Children, commencing July 17, 2013, and ending May 31, 2014, and Shiloh Home, Inc., commencing August 31, 2013, and ending May 31, 2014, with further terms and conditions being as stated in said agreement, 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 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, with the Tennyson Center for Children, and the Shiloh Home, Inc., 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 7th day of October, A.D., 2013, nunc pro tunc July 17, 2013, and August 31, 2013, respectively. BOARD OF COUNTY COMMISSIONERS WELD C , COLORADO ATTEST p''"r-s"""-‘C ^- Weld County Clerk to the Board BY Deputy AP -PRO Corey Attorney OCT 1 6 2013 Date of signature: Garcia, Chair �aci,„e--- Douglas/Rademacher, Pro-Tem can P. Conway ma 4, ke Freeman Barbara Kirkmeyr / 2013-2827 HR0084 MEMORANDUM DATE: October 3, 2013 TO: William F. Garcia, Chair, Board of county mi,8 ioners FROM: Judy A. Griego, Director, Human SUBJECT: Child Protection Agreement for Services between the Weld County Department of Human Services and Various Providers Enclosed for Board approval is a Child Protection Agreement for Services between the Department and Various Providers. These Agreements were reviewed under two (2) separate Board Pass - Around Memorandums; one dated August 15, 2013, and the other dated September 17, 2013. Both Agreements were approved for placement on the Board's Agenda. The major provisions of the Agreement approved August 15, 2013, are as follows: No. Contractor/Term Services/Funding Rate 1 Tennyson Center for Children July 17, 2013 — May 31, 2014 Day Treatment Services Core $1,680.96/Month (Pro -Rated for any partial month of services) The major provisions of the Agreement approved September 17, 2013, are as follows: No. Contractor/Term Services/Funding Rate 1 Shiloh Home August 31, 2013 — May 31, 2013 Life Skills Core $46.00/Hour for between 4.5 to 8 hours total per week (all three boys combined). Maximum weekly cost range is $207.00-$368.00 (a11 three boys combined). Boys will actually receive 12 hours per week (6 on Saturday, 6 on Sunday) at the facility but Shiloh will only charge for 4.5 to 8 per week. If you have any questions, give me a call at extension 6510. 2013-2827 (97-& -/Stiff `' PY-13-14-CORE-0239 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND TENNYSON CENTER FOR CHILDREN This Agreement, made and entered into the d ay of�Lx7` , 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 Tennyson Center for Children, 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 July 17, 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 established by the Department. CONTRACTOR shall submit all itemized monthly billings to the 1 62r7/9- (57a PY-13-14-CORE-0239 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. sep.; 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-0239 • 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 a 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-0239 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-0239 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-0239 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-0239 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: Kimberly Behounek Name 17. Notice Administrator Title Director of Admissions and Quality Assurance 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: Pam Hricik, Chief Program Officer 2950 Tennyson Street Denver, CO 80212 (720) 855-3346 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-0239 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 17. 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-0239 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-0239 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-0239 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: unty Attorney By: WELD COUNTY DEPARTMENT OF HUMAN SERVICES 11 BOARD OF COUNTY COMMISSIONERS WELD CO Y, COLORADO /y! F. Garcia, Chair OCT 0 7 2013 CONTRACTOR: By: Contractor Ci^^ t -F P1 +,_ U7 h 8125/4 Title t2©/3-dea? 7 PY-13-14-CORE-0239 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide comprehensive, highly structured day treatment services, as proposed, to female and male children, grades K-12, as referred by the Department. 2. CONTRACTOR will provide day treatment services, as proposed, at 2950 Tennyson Street, Denver, CO 80212- 3029, Monday through Friday, year round. School hours are Monday, Tuesday, Thursday and Friday, 7:45 a.m. to 2:30 p.m., and Wednesday, 7:45 a.m. to 12:30 p.m. 3. CONTRACTOR is accredited by North Central Association Commission on Accreditation of School Improvement and licensed by the Colorado Department of Human Services State Child Care Licensing (license number 1529815). Program supervision is provided by a Master's level clinician. 4. CONTRACTOR is a Medicaid approved provider. Medicaid will be accessed first for those clients eligible for services so long as Medicaid is approved. CONTRACTOR will notify the Department, via caseworker and the Child Welfare Contract and Services Coordinator, of the lapse in funding so that alternative funding can be authorized if appropriate, and so long as funding is available. 5. CONTRACTOR will focus on stabilization of social and emotional issues for students within the classroom and family setting so student may return to a long term educational placement. Students appropriate for this program may exhibit social and/or emotional issues as a result of attachment disruptions, mental illness, sexually reactive or abusive behaviors, and/or are a witness to, or victim of, violence resulting in violent behavioral outbursts that prevent the student from remaining in a less restrictive educational placement. 6. CONTRACTOR utilizes a strengths -based approach with trauma informed care principles embedded in daily practice (safety, choice, collaboration, empowerment, and trustworthiness). Positive behavior is reinforced through a Positive Behavior Intervention Support (PBIS) program, trauma -informed care principles, and Love & Logic. Clinicians utilize family systems theory, Cognitive Behavioral Theory (CBT), Dialectical Behavior Theory (DBT), Eye Movement Desensitization and Reprocessing (EMDR), and Multisystemic (MST) informed modalities. 7. The primary goals of service are to provide the following for each referred client: a. Improvement in the CANS with 75% of treatment goals reached, b. Improved academics and public school readiness behaviors, c. Increased family response (parenting, involvement in program, follow through), d. Crisis stabilization following higher level of care; and, e. Acquisition of new skills by client and parent(s) that contribute to successful transition to a long term educational placement. 8. Teacher/Student ratio is 1:12 with two (2) youth treatment counselors in each classroom. 9. CONTRACTOR will provide individual, group and family therapy, unless otherwise directed by the Department. Family therapy can be provided in -home if clinically appropriate. Additionally, CONTRACTOR will provide psychiatric services, case management, assessment and treatment planning at no additional cost. 10. CONTRACTOR will assign each referred client a Master's level clinician. 11. All classes are taught by Master's level special education teachers. 12. CONTRACTOR is able to provide bilingual services. 12 PY-13-14-CORE-0239 13. Referred youth will receive services for approximately (6) months (average length of stay). Length of services is dependent upon the referred youth's daily/weekly progress, individual/family needs and availability of funding. Services will include, but are not limited to, the following as appropriate: a. Immediate family interventions. b. Evaluation and placement. c. Individualized treatment and plans. d. Individual educational assessment and learning programs. e. Individual therapy f. Family therapy g. Group therapy h. Recreational therapy i. Parent support group j. 24 -hour on -cal therapists available k. Transportation — Provided within the boundaries 52nd Street, Colorado Boulevard, Hampden Avenue, and Wadsworth Boulevard. Transportation outside of these boundaries and not paid for by the referred client's school district shall be billed separately to the Department (actual transportation costs only). I. Reintegration into home school m. Ongoing psychiatric evaluation and consultation n. Academic instruction designed to meet the needs of the referred student o. Case management 14. 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. 15. 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. 16. 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. 17. 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. 18. 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. 19. Services are inclusive of attendance at staffings, Family Team Meetings (FTM) and/or Team Decision Making (TDM) meetings. Staffings and/or meetings are not considered billable hours unless otherwise approved by the Child Welfare Contract and Services Coordinator. 13 PY-13-14-CORE-0239 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 $1,680.96/Month (Day Treatment Services. 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-0239 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-0239 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-0239 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-0239 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 11`h 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-0239 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 19 PY-13-14-CORE-0239 13 a o ,• Q{«z N - CD O ) 0 [ / O $ § so ; j §2 _ §(/ )j( g • }) r 8 / $/ \/\ its to )\ )2103 ®;/); Lc < o IQo CN .23 02 2 c) CD CD < • a. 2 CD CV 00 0 CD 2 <• oo2 O) O TD -C sal § t#[ fz FrD \\ §f CO 00 00 CO CO 2 } Z2 0! ( <La 0 WELD COUNTY DEPARTMENT OF HUMAN SERVICES PY-13-14-CORE-0239 CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) N C1 a al .O O 'O al a C a L a) 3 E al V a W CI ❑ N y 0 C T N L E •> al a 0 8 L fN0 7 C Cr al O al Z N . 0 CI ` Z m a N 'C o E E X H � a, E IVal d E C y0 a w N > Z N d t N 0 a aj d � O N a E L O C O O E ro ai � _ 2 QI al m s c al C u C .0 7 '0 C/ '0 C a 00 Z N v Co c o ar 0. __ ro L d T O .0 a a c O E I..? o O M Ct 4a1 N .. O C Z Section I: (To be completed by the CONTRACTOR) Total Hours Billed Primary Client billed: -.one 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 C O 0 CI .0 O Co A n r CI .0 .0 d CI 7 E C)C) C T A R. w CI Q to C .0 0 t C £ .0 0 CI C L C 0 E Cl O CN E O C 0 Cl C s u m Qs - 0 Q CG O a z 0 V 0 d O z the month of service. PY-13-14-CORE-0240 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND SHILOH HOME, INC. 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 Shiloh Home, Inc., 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 (Children 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 August 31, 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 (��' UI Oa7 C PY-13-14-CORE-0240 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 „r PY-13-14-CORE-0240 • 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; 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 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 „r PY-13-14-CORE-0240 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-0240 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 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 5 It r PY-13-14-CORE-0240 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. 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 PY-13-14-CORE-0240 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: Steven Ramirez. Name 17. Notice Administrator Title Chief Executive Officer 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: Steven Ramirez, Chief Executive Officer 6400 West Coal Mine Avenue Littleton, CO 80123 (303) 932-9599 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. 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 17. 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 7 t , 1 PY-13-14-CORE-0240 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 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 8 PY-13-14-CORE-0240 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. 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 9 ♦1 , PY-13-14-CORE-0240 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 entitledto 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-0240 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 WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: 2 A `. rney 11 BOARD OF COUNTY COMMISSIONERS WELD COUfjLt , COLORADO F. Garcia, Chair OCT 0 7 2013 Title 0a/3- c9 Pal r, I PY-13-14-CORE-0240 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Life Skills services to Z.T., N.T. and M.T, Trails Case ID 1714304, who speak English, as referred by the Department. 2. Services will be provided weekly on Saturday and Sunday for six (6) hours per day. 3. Services will be provided at 8461 Delaware Street, Thornton, CO 80260, or other location agreed to by the CONTRACTOR and the Department. 4. Parent(s) of will transport the three youth to and from the service location. 5. 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. 6. 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. 7. 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. 8. CONTRACTOR will submit one brief report on a monthly basis for the duration of services that summarizes the services provided to the three referred youth (Z.T., N.T., and M.T.) as well as any observations and/or recommendations. The CONTRACTOR will create this report and is not required to use the Department's online reporting system. 9. 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. 10. CONTRACTOR may bill for actual participation in Team Decision Making (TDM) meetings and Family Team Meetings (FTM), when pre -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. Travel time is not reimbursed as provider may appear by phone. 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-024O 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 $46.00/Hour (CONTRACTOR agrees to bill 4.5 to 8 hours total per week, for a 12 hour service period per week, inclusive of all three referred youth. Maximum weekly reimbursement allowable under this agreement is $207.00-$368.00. CONTRACTOR will bill the minimum of 4.5 hours per week unless otherwise agreed to by the Department.). $46.00/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. 13 PY-13-14-CORE-0240 b. For Monitored Sobriety services, proof of services rendered shall be a sign -in sheet with client signatures or the test result. 14 r' ✓ PY-13-14-CORE-0240 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. Permanency Outcomes 15 PY-13-14-CORE-0240 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 t„ I NA. r PY-13-14-CORE-0240 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 1,44 s,6r PY-13-14-CORE-0240 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) completed Request for Reimbursement form, 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 Client Verification Form WILL NOT be accepted. 3) All billings should be submitted to: loceyln Florez, Fiscal Clerk WCDHS/Service Utilization Unit Mailing Address: P.O. Box A, Greeley, CO 80632 Physical Address: 315 A North il`h 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-0240 Weld County Contracted Services Request for Reimbursement (SAMPLE ONLY. ACTUAL FORM IS IN EXCEL AND WILL BE SENT TO CONTRACTOR.) Program Area (Ex. Lifeskills, Mental Health, Option B, etc.) Client Name (Per Referral) SAMPLE ENTRY: Doe, John Trails Case ID (Per referral) 1654888 Household Number (Per referral) 555555 Approved Start Date (Per referral) 6/1/2009 Month/Year of Service Approved End Date (Per referral) 8/30/2009 Date(s) of Service 06/01, 06/02 Actual Hours or Units /Service Period 12 Rate per Hour or Unit 25 Submit To Jocelyn Florez, Fiscal Clerk. Weld County Department of Human Services P.O. Box A/315 A N 11th Ave.,.. Greeley, 80632 (970) 352-1551, ext. 6392 .(970)346-7667 (Fax) For Use By, Human Services Only Monthly Total' (Calculates automatically) 300.00 Comments' TOTALS (Caldulate'Automaticaliy) 19 2 300.00 Lv •as -aa[ PY-13-14-CORE-0240 WELD COUNTY DEPARTMENT OF HUMAN SERVICES CONTRACTED SERVICES CLIENT VERIFICATION FORM (SAMPLE ONLY. ACTUAL FORM WILL BE SENT TO CONTRACTOR) Notice to CONTRACTOR: All clients served during the service month must complete this verification form at the time of service. No request for payment of services will be honored for billed services unless accompanied by the appropriate signed Client Verification Form. Payment for services will not exceed maximum hours or sessions authorized by the Department. Section I: (To be completed by the CONTRACTOR) Primary Client billed: Trails ID Household Number: Your Agency's Contact Person: SECTION II (To be completed by client) Notice to Client Your gnature must be obtained al the tine of service. Your signature verifies that services were provided by the service CONTRACTOR for direct face-to-face contact only, for the hours and date indicated. Total Hours Billed Phone Number Date Hours of Service (Ex. 1:00 — 2:30) Number of Hours of Service Provided 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) Notice to CONTRACTOR:Atta h all client verification forms to the monthly hi ing'when submitting your billingAll requests for payment must be received by the 7 day of the month following the month of service. 20 Hello