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Home My WebLink About20122164.tiff RESOLUTION RE : APPROVE SIX (6) CHILD PROTECTION AGREEMENTS FOR SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado , pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado , and WHEREAS , the Board has been presented with six (6) Child Protection Agreements for Services between the County of Weld , State of Colorado , by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and the various providers listed in Exhibit "A" , a copy of which is attached hereto and incorporated herein by reference, commencing June 1 , 2012 , and ending May 31 , 2013 , with further terms and conditions being as stated in said agreements , and WHEREAS, after review, the Board deems it advisable to approve said agreements, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado that six (6) Child Protection Agreements for Services between the County of Weld , State of Colorado , by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services , and the providers listed in Exhibit "A" , a copy of which is attached hereto and incorporated herein by reference 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 15th day of August, A. D . , 2012 , nunc pro tunc June 1 , 2012 . BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: Sean P . C ay, Chair Weld County Clerk to the Board William F . arcia , Pro- eynJ BY: tip' � �tl ) , ' Deputy CI - to th - ' Board 0, ; • �" arba a Kirkmeyer °°". i`avid E . Long " Attorney _U \ D Se # v Douglas Radem - c er Date of signature: I CC • NSfl e - \ a-\ a 2012-2164 HR0083 18661 MEMORANDUM DATE: August 13, 2012 UG U N ' � TO: Sean P. Conway, Chair, Board of County Commissione FROM: Judy A. Griego, Director, Human Services/j partmejrt C SUBJECT: Child Protection Agreements for Services between the Weld County Department of Human Services and Various Providers Enclosed for Board approval are Child Protection Agreements for Services between the Department and Various Providers. These Agreements were reviewed under the Board's Pass-Around Memorandum dated May 7, 2012, and approved for placement on the Board's Agenda. There were a total of 50 agreements with various providers,the following represent the last 6 agreements needing to be signed by the Board Chair. The major provisions of these Agreements are as follows: Program Area/ No. Provider Funding Source Services/Rates 1 Perklen, Inc., dba Perklen Anger Management/ $210.00 (Anger Management/Domestic Center for Psychotherapy Domestic Violence Violence Evaluation) $70.00/hr(Anger Management/Domestic 06/01/12-05/31/13 CW Admin Violence Evaluation Hourly Rate -Not to exceed cost of full evaluation.) $575.00 (Domestic Violence Assessment) $144/hr(Domestic Violence Assessment Hourly Rate -Not to exceed cost of full assessment.) $20.00/hr(Domestic Violence Education) $20.00/hr(Caring Dads Group) $20.00/hr(Mothers Parenting Group) $37.50 (Standard Group Session) $70.00/hr(Domestic Violence Impact) $70.00/hr(Individual Session- In-Office) $85.00/hr(Individual Session - Off-Site) $90.00/hr(Family Session) 2 Perklen, Inc., dba Perklen Mental Health $210.00 (Anger Management/Domestic Center for Psychotherapy Violence Evaluation) Core $70.00/hr(Anger Management/Domestic 06/01/12-05/31/13 Violence Evaluation Hourly Rate-Not to exceed cost of full evaluation.) $575.00 (Domestic Violence Assessment) $144/hr(Domestic Violence Assessment Hourly Rate -Not to exceed cost of full assessment.) $20.00/hr(Domestic Violence Education) $20.00/hr(Caring Dads Group) 2012-2164 $20.00/hr(Mothers Parenting Group) $37.50 (Standard Group Session) $70.00/hr(Domestic Violence Impact) $70.00/hr(Individual Session - In-Office) $85.00/hr(Individual Session -Off-Site) $90.00/hr(Family Session) 3 Perklen, Inc., dba Perklen Sexual Abuse Treatment $70.00/hr(Individual Session -In-Office) Center for Psychotherapy $85.00/hr(Individual Session -Off-Site) Core $90.00/hr(Family Session) 06/01/12-05/31/13 $70 (Juvenile Sex Offender Intake) $37.50 (Juvenile Sex Offender Group) $37.50 (Juvenile Sex Offender Education Group) $450.00 (Juvenile Sex Offender Evaluation without Testing- 13 years and younger) $150.00/hr(Hourly rate - Adult or Juvenile Sex Offender Evaluations partially completed. Not to exceed cost of full evaluation.) $600.00 (Juvenile Sex Offender Evaluation with Testing and without PPG/Abel - 14 years and older) $900.00 (Juvenile Sex Offender Evaluation with Testing and a PPG/Abel) $600.00 (Adult Sex Offender Evaluation without Testing and PPG/Abel) $900.00(Adult Sex Offender Evaluation with Testing and PPG/Abel) $800.00 (Adult Sex Offender Evaluation with Testing and without PPG/Abel) $600 (Adult SO Eval Update) $50.00 (Additional charge/evals off-site.) 4 Victor H. Cordero, Ph.D. Mental Health $800.00 (Mental Health Assessment) $1,000.00 (Interactional) 06/01/12-05/31/13 Core $500.00 (Interactional/Additional Parent) $1,200.00 (Psychological or Psychosexual Evaluation) $350.00/hr(Hourly rate for partially completed MHA or PE. Not to exceed cost of full MI-IA or PE. $100.00/hr(Individual Therapy) $120.00/hr(Family Therapy) 5 Wurth, Helene Foster Parent $100.00/hr(Foster Parent Consultation) Consultation 06/01/12-05/31/13 6 Wurth, Helene Home Studies/ $950.00 (Full Home Study) Relinquishment $450.00 (Home Study Update) 06/01/12-05/31/13 Counseling $200.00 (Additional Adult) $50.00/hr(Cancellation by WCDHS) CW Admin $100.00/hr(Relinquishment Counseling) $35.00/hr(Interpretive Services) If you have any questions, give me a call at extension 6510. PY-12-13-CORE-0160 ////yr CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND PERKLEN,INC.,DBA PERKLEN CENTER FOR PSYCHOTHERAPY This Agreement, made and entered into the day of ,2012,by and between the Board of Weld County Commissioners,sitting as the Board of Human Services,on behalf of the Weld County Department of Human Services,hereinafter referred to as the"Department"and Perklen, Inc., dba Perklen Center for Psychotherapy,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 Sexual Abuse Treatment(Offense Specific);and NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1,2012 upon proper execution of this Agreement and shall expire May 31,2013 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization,billing and tracking requirements as outlined in Exhibit D"Process Reference Guide",of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B"Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 ao/a-a/O PY-12-13-CORE-0160 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement,whether in whole or in part,is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for,and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement,CONTRACTOR shall comply with the administrative requirements,cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives,contractual terms,or reporting requirements. In the vent of forfeiture of reimbursement,CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including,but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement,CONTRACTOR shall strictly adhere to all applicable Federal and State laws,orders, and all applicable standards, regulations,interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents,tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-1 et seq. and its implementing regulation,45 C.F.R. Part 80 et.seq.;and 2 PY-12-13-CORE-0160 • All provisions of Civil Rights Act of 1986 so that no person shall,on the grounds of race,creed, color,se,or national origin, be excluded from participation in, be denied the benefits of,or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973,29 U.S.C.Section 794, and its implementing regulations,45 C.F.R. Part 84;and • the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et. seq. and its implementation regulations,45 C.F.R. Part 91;and • Title VII of the Civil Rights Act of 1964;and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963;and • the Education Amendments of 1972;and • Immigration Reform and Control Act of 1986, P.L.99-603 • 42 C.F.R. Part 2;and all regulations applicable to these laws prohibiting discrimination because of race,color, National origin,and sex, religion and handicap,including Acquire Immune Deficiency Syndrome(AIDS)or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973,as amended,cited above. If necessary,CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute(C.R.5.)26-6-104, requiring criminal background record checks for all employees,CONTRACTORS,and sub-contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services,Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred,suspended, proposed for debarment,declared ineligible,or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not,within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing a public (federal,state or local)transaction or contract under a public transaction;violation of federal or state antitrust statues or commission of embezzlement,theft,forgery, bribery,falsification or destruction of records, making false statements,or receiving stolen property; Hi. Are not presently indicted for other otherwise criminally or civilly charged by a government entity(federal,state,or local)with commission of any of the offenses enumerated in paragraph 12 of this certification;and 3 PY-12-13-CORE-0160 iv. Have not,within a three-year period preceding this Agreement, had one or more public transactions(federal,state,and local)terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.)8-17.5-101,et.seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents,warrants, and agrees that is(a) has verified that it does not employ any illegal aliens,through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security,and(b)otherwise will comply with the requirements of C.R.S.8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S.8-17.5-101,et.seq.,the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S.24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement,CONTRACTOR must confirm that any individual natural person eighteen(18)years of age or older is lawfully present in the United States pursuant to C.R.S.24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is(a)is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law,(b)shall produce one of the forms of identification required by C.R.S. 24-76.5-101,et seq.,and (c)shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review,a Program Improvement Plan (PIP)will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s)identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas,unless otherwise determined by the Department. 9. Insurance Weld County,the Board of County Commissioners of Weld County,its officers and employees,shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR,its subcontractor,or their employees,volunteers, or agents while performing duties described in this 4 PY-12-13-CORE-0160 Agreement. CONTRACTOR shall indemnify,defend,and hold harmless Weld County,the Board of County Commissioners of Weld County, its employees,volunteers and agents. Therefore,CONTRACTOR shall provide adequate liability(including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteer,and agents engaged in the performance of the Agreement. Upon request,CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum,CONTRACTOR,shall procure,either personally or through its employer as applicable to the CONTRACTOR'S business,at its own expense,and maintain for the duration of the work,the following insurance coverage. Weld County,Colorado, by and through the Board of County Commissioners of Weld County,its employees and agents,shall be named as additional named insured on the insurance,where , permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease,covering all employees at work site. • General Liability(PL and PD)(Minimum). o Combined single limit-$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below$500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability(Minimum)for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement,a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that,at the time of entering into this Agreement,it has currently in effect all necessary licenses,approvals, insurance,etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-12-13-CORE-0160 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-12-13-CORE-0160 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 Administrator Name Title For Contractor: Kim Ruybal President Name Title 17. Notice 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: For Contractor: Judy A.Griego, Director Kim Ruybal, President P.O. Box A 1020 8th Street Greeley,CO 80632 Greeley,CO 80631 1970)352-1551 {970)353-8171 18. Litigation 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-12-13-CORE-0160 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld,State of Colorado,to expend funds not otherwise appropriated in each succeeding year,as this Agreement is subject to the availability of funding. Therefore,the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement,and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver,express or implied,of any of the immunities,rights, benefits, protections or other provisions,of the Colorado Governmental immunity Act§§24-10-101 et seq.,as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section,subsection, paragraph,sentence,clause,or phrase of this Agreement is for any reason held or decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph,sentence,clause, and phrase thereof irrespective of the fact that any one or more sections,subsections,paragraphs,sentences,clauses,or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer,member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest,direct or indirect,in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-12-13-CORE-0160 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. CONTRACTOR shall advise its employees,agents, and sub-contractor,if any,that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees,agents,and sub-contractors,if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees,agents,and subcontractors,if any,sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-12-13-CORE-0160 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-12-13-CORE-0160 IN WITNESS WHEREOF,the parties hereto have • I executed the Agreement as of the day,month, and year first above written. E. am` ATTEST: �', ARD OF COUNTY COMMISSIONERS Nyi 361 t LD COUNTY,COLORADO //V ,) Weld County Clerk to the Board Sean P.Conway,Chair 2 �) AUG 1 5 2 By: Deputy Clerk to e Board APPRO AS TO F Cou Attorne WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SE VICES { By: By: Lf , C \ ' Flg? .+Q Ju y .Griego Directo Contractor Sjgl2ar2. Title 11 a©�� a/c PY-12-13-CORE-0160 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide offense specific evaluation and treatment services to male and female juveniles and adults, including developmentally disabled individuals, and same sex,in Weld County,as referred by the Department. 2. Services available under this contract include: - Psychosexual testing and evaluation. - Offense-specific group therapy. - Individual or family therapy. - Relationship and interpersonal social skills. - Sex education. - Interdisciplinary team meetings. - Victim empathy and awareness. - Anger management/impulse control skills. - Cognitive behavioral modification. - Self-esteem building. - Values clarification and examination. - Relapse prevention plan. - Aftercare services. 3. The following Perklen staff are approved by the Department to conduct Sex Offender Management Board (SOMB)evaluations: - Kim Ruybal,MA,LPC,NCACII(SOMB Full Operating Level Supervisor) - Jodie Goter,MA,LPC(SOMB Full Operating Level Treatment Provider) - Aaron Henderson, MA(SOMB Associate Level) 4. All evaluations will be conducted under the supervision of by Kim Ruybal, MA, LPC,NCAC II. Ms. Ruybal will also review and sign all evaluations. 5. Evaluations will examine six key areas: - Potential to reoffend - Amenability for treatment - Recommended treatment setting - Type of treatment needed - Risk factors/monitoring/potential new victims - Psychiatric/substance abuse/individual/family needs - Mental health concerns. 6. Evaluations will include the following: - Structured clinical interview - Collateral information from schools,caseworkers,probation/parole officers,case managers, therapists,doctors,courts,police reports and/or other relevant sources. - Other assessment tools(depending on the age of the offender and circumstances of the case). Assessment tools many include any of the following: - Shipley Institute of Living Scale - Millon Clinical Multiaxial Inventory(MCMI) - Minnesota Multiphasic Personality Inventory-II (MMPI-II) - SASSI-Ill Drug and Alcohol Inventory - Jesness Inventory - State Trait Angry Inventory-II - Violence risk Assessment Guide 12 PY-12-13-CORE-0160 - Hare Psychopathy Checklist-Revised - Wilson Sex Fantasy Questionnaire - Multiphasic Sex Inventory - Millon Clinical Adolescent Inventory - Sex Offender Needs Assessment Guide - Penile Plethysmograph - Abel Assessment for Sexual Interests - Juvenile Sex Offender Assessment Protocol-II 7. For evaluation services,CONTRACTOR will submit a written document outlining recommendations for treatment,further assessment, and risk to repeat similar behavior.CONTRACTOR will provide a copy of the evaluation to the caseworker. 8. All services will comply with the Colorado Sex Offender Management Board(SOMB)Standards and Guidelines for for juveniles,adults and developmentally delayed offenders. 9. 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. 10. 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. 13 PY-12-13-CORE-0160 11. 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. 12. 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. 13. CONTRACTOR will participate in team reviews of ongoing services as needed. These will primarily include staffings and Utilization Review Team(URT)and are not considered billable hours. 14 PY-12-13-CORE-0160 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2,below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31,2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds,or any part thereof, become unavailable as determined by the Department,the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $70.00/Hour(Individual Session -In-Office) $85.00/Hour(Individual Session -Off-Site) $90.00/Hour(Family Session) $70.00/Episode(Juvenile Sex Offender Intake) $37.50/Episode(Juvenile Sex Offender Group) $37.50/Episode(Juvenile Sex Offender Education Group) $450.00/Episode(Juvenile Sex Offender Evaluation without Testing-13 years or Younger) $150.00/Hour(Adult or Juvenile Sex Offender Evaluations-Hourly rate for partial evaluations. Not to exceed the cost of full evaluation.) $600.00/Episode(Juvenile Sex Offender Evaluation with Testing and without PPG/Abel -14 years or older) $900.00/Episode(Juvenile Sex Offender Evaluation with Testing and PPG/Abel) $600.00/Episode(Adult Sex Offender Evaluation without Testing or PPG/Abel) $900.00/Episode(Adult Sex Offender Evaluation with Testing and PPG/Abel) $800.00/Episode(Adult Sex Offender Evaluation with Testing and without PPG/Abel) $600.00/Episode(Adult Sex Offender Evaluation Update) $50.00/Episode(Additional charge per evaluation for evaluations completed off-site.) 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. 15 PY-12-13-CORE-0160 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. a. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. 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. c. For Monitored Sobriety services, proof of services rendered shall be a sign-in sheet with client signatures or the test result. 16 PY-12-13-CORE-0160 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. 17 PY-12-13-CORE-0160 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out-of-home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made,in the CONTRACTORs'opinion. • CONTRACTORs should continually assess family relationships(parent/child,sibling/sibling,extended family/child,etc.)and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well-Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents'capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical, emotional,educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. `Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 18 PY-12-13-CORE-0160 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 from the Core and Contracted Services Coordinator or Service Utilization Assistant. 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 Core and Contracted Services Coordinator for a referral. 3) Referrals for ongoing services (visitation,therapy, home-based, etc.) are reviewed by the Department's Utilization Review Team (URT) prior to the referral end date. 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 can attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Core and Contracted Services Coordinator,the Service Utilization Manager or the Utilization Review Team. 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 one of the abovementioned parties for proper authorization. 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. 19 PY-12-13-CORE-0160 3) If the client receives services over multiple dates,then the client must sign at the time of service for each date(appointment). 4) If a child is receiving services and is unable to sign,then an appropriate person should sign for the child and indicate their relationship to the child (ex.Jane Smith,foster mom,for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only,should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7`h of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2)the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures. 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: Tobi Vegter Core and Contracted Services Coordinator WCDHS/Service Utilization Unit Mailing Address: P.O.Box A,Greeley,CO 80632 Physical Address: 315 A North 11"'Avenue,Greeley,CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 20 PY-12-13-CORE-0160 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month /Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. 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N V �. a E 7 b 7 •0 d O c d O W O C I I Z r CL 2 = N a 2 h Z L PY-12-13-CORE-0140 OPA// CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND PERKLEN,INC.,DBA PERKLEN CENTER FOR PSYCHOTHERAPY This Agreement, made and entered into the day of 2012, by and between the Board of Weld County Commissioners,sitting as the Board of Human Services,on behalf of the Weld County Department of Human Services,hereinafter referred to as the"Department"and Perklen, Inc., dba Perklen Center for Psychotherapy, hereinafter referred to as the"Contractor". WITNESSETH WHEREAS, required approval,clearance, and coordination have been accomplished from and with appropriate agencies;and WHEREAS,the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services; and NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1,2012 upon proper execution of this Agreement and shall expire May 31,2013 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D"Process Reference Guide",of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B"Payment Schedule,"of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 aO/02- OV641 PY-12-13-CORE-0140 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for,and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement,CONTRACTOR shall comply with the administrative requirements,cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives,contractual terms,or reporting requirements. In the vent of forfeiture of reimbursement,CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement,CONTRACTOR shall strictly adhere to all applicable Federal and State laws,orders,and all applicable standards, regulations,interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records,papers, documents,tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d-1 et.seq. and its implementing regulation,45 C.F.R. Part 80 et seq.;and 2 PY-12-13-CORE-0140 • All provisions of Civil Rights Act of 1986 so that no person shall,on the grounds of race,creed, color,se,or national origin, be excluded from participation in,be denied the benefits of,or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973,29 U.S.C.Section 794,and its implementing regulations,45 C.F.R. Part 84;and • the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et.seq. and its implementation regulations,45 C.F.R. Part 91;and • Title VII of the Civil Rights Act of 1964;and • the Age Discrimination in Employment Act of 1967;and • the Equal Pay Act of 1963;and • the Education Amendments of 1972;and • Immigration Reform and Control Act of 1986, P.L.99-603 • 42 C.F.R. Part 2;and al!regulations applicable to these laws prohibiting discrimination because of race,color, National origin,and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS)or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973,as amended,cited above. If necessary,CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute(C.R.S.)26-6-104, requiring criminal background record checks for all employees, CONTRACTORS,and sub-contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services,Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred,suspended,proposed for debarment, declared ineligible,or voluntarily excluded from covered transaction by a federal department or agency. H. Have not,within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing a public (federal,state or local)transaction or contract under a public transaction;violation of federal or state antitrust statues or commission of embezzlement,theft,forgery, bribery,falsification or destruction of records, making false statements,or receiving stolen property; Hi. Are not presently indicted for other otherwise criminally or civilly charged by a government entity(federal, state,or local)with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-12-13-CORE-0140 iv. Have not,within a three-year period preceding this Agreement, had one or more public transactions(federal,state,and local)terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.)8-17.5-101,et.seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents,warrants, and agrees that is(a) has verified that it does not employ any illegal aliens,through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security,and(b)otherwise will comply with the requirements of C.R.S.8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S.8-17.5-101,et.seq.,the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S.24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement,CONTRACTOR must confirm that any individual natural person eighteen(18)years of age or older is lawfully present in the United States pursuant to C.R.S.24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is(a)is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law,(b)shall produce one of the forms of identification required by C.R.S.24-76.5-101,et seq., and (c)shall produce one of the forms of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review,a Program Improvement Plan(PIP)will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s)identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County,the Board of County Commissioners of Weld County, its officers and employees,shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR,its subcontractor,or their employees,volunteers,or agents while performing duties described in this 4 PY-12-13-CORE-0140 Agreement. CONTRACTOR shall indemnify,defend,and hold harmless Weld County,the Board of County Commissioners of Weld County, its employees,volunteers and agents. Therefore,CONTRACTOR shall provide adequate liability(including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteer,and agents engaged in the performance of the Agreement. Upon request,CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR,shall procure,either personally or through its employer as applicable to the CONTRACTOR'S business,at its own expense,and maintain for the duration of the work,the following insurance coverage. Weld County,Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents,shall be named as additional named insured on the insurance,where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease,covering all employees at work site. • General Liability(PL and PD)(Minimum). o Combined single limit-$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below$500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability(Minimum)for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement,a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that,at the time of entering into this Agreement,it has currently in effect all necessary licenses,approvals, insurance,etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-12-13-CORE-0140 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-12-13-CORE-0140 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 Administrator Name Title For Contractor: Kim Ruybal President Name Title 17. Notice 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: For Contractor: Judy A.Griego, Director Kim Ruybal, President P.O. Box A 1020 8th Street Greeley,CO 80632 Greeley,CO 80631 1970)352-1551 1970)353-8171 18. Litigation 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-12-13-CORE-0140 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld,State of Colorado,to expend funds not otherwise appropriated in each succeeding year,as this Agreement is subject to the availability of funding. Therefore,the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement,and all rights of action relating to such enforcement,shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver,express or implied,of any of the immunities, rights, benefits, protections or other provisions,of the Colorado Governmental immunity Act§524-10-101 et seq.,as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph,sentence,clause,or phrase of this Agreement is for any reason held or decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph,sentence,clause,and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs,sentences,clauses,or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest,direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest,it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-12-13-CORE-0140 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. CONTRACTOR shall advise its employees,agents, and sub-contractor, if any,that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents,and sub-contractors, if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees,agents,and subcontractors,if any,sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-12-13-CORE-0140 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-12-13-CORE-0140 IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day, month,and year first above written. ATTEST: `BOARD OF COUNTY COMMISSIONERS l% ELD COUNTY,COLORADO Weld County Clerk to the Board Lean P. Conway,Chair AUG 1 5 By: AL" P- Deputy Clerk to Board APP AS TO FO Co ty Attorne WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES 1 .l By: By: l�-Ch -C) J d A.Grieg , Directo Contractor <Z191202— Title 11 &C/& -O,7 PY-12-13-CORE-0140 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Mental Health evaluation and treatment services to male and female adults and juveniles, including developmentally disabled individuals and same sex,in Weld County,who are 10 years of age or older. 2. If referred for evaluation,two(2)to three(3)sessions will be needed to complete the requirements of the evaluation or assessment. 3. Following evaluation sessions,CONTRACTOR will pose questions designed to gather basic identifying information,examine the client's mental status/mental health issues, and various history(mental health, family/medical,substance abuse,inpatient/outpatient,current social, and criminal). 4. CONTRACTOR will utilize a variety of psychometric assessment tools that may include any of the following: - Shipley Institute of Living Scale - Millon Clinical Multiaxial Inventory(MCMI) - Minnesota Multiphasic Personality Inventory-II (MMPI-II) - SASSI-Ill Drug and Alcohol Inventory - Jesness Inventory - State Trait Angry Inventory-II - Violence risk Assessment Guide, Domestic Violence Risk Needs Assessment - Domestic Violence Screening Instrument - Spousal Assault Risk and Assessment - Hare Psychopathy Checklist-Revised - Wilson Sex Fantasy Questionnaire - Multiphasic Sex Inventory - Millon Clinical Adolescent Inventory 5. For evaluation services,CONTRACTOR will submit a written document outlining recommendations for treatment,further assessment,and risk to repeat similar behavior.CONTRACTOR will provide a copy of the evaluation to the caseworker. 6. 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. 7. 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. 8. 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. 9. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 12 • PY-12-13-CORE-0140 10. CONTRACTOR will participate in team reviews of ongoing services as needed. These will primarily include staffings and Utilization Review Team(URT)and are not considered billable hours. 13 PY-12-13-CORE-0140 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31,2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds,or any part thereof, become unavailable as determined by the Department,the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $575.00/Episode(Mental Health Evaluation with HARE, PCLR,VRAG) $144.00/Hour(Mental Health Evaluation-Hourly rate for partial completed evaluations. Not to exceed cost of full evaluation.) $50.00/Episode(Additional charge for jail evaluations.) $70.00/Hour(Individual Session -In-Office) $85.00/Hour(Individual Session-Off-Site) $90.00/Hour(Family Session) 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. a. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7ch day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. 14 PY-12-13-CORE-0140 b. 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. c. For Monitored Sobriety services, proof of services rendered shall be a sign-in sheet with client signatures or the test result. 15 PY-12-13-CORE-0140 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS(CFSR) The Child and Family Services Reviews(CFSR)examines child welfare service outcomes in three areas;Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review,a Performance Improvement Program (PIP)will be implemented for the state to enhance services to families. Additionally,the review will assess statewide,systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area,the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety,permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being,followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are,first and foremost,protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats,or the caregivers'protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats,and caregivers are unable or unwilling to provide protection. o Risk is the likelihood(chance, potential,prospect)for parenting behavior that is harmful and destructive to a child's cognitive,social,emotional and/or physical development,and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 16 PY-12-13-CORE-0140 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out-of-home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made, in the CONTRACTORs'opinion. • CONTRACTORs should continually assess family relationships(parent/child,sibling/sibling,extended family/child,etc.)and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well-Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents'capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical,emotional,educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-12-13-CORE-0140 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 from the Core and Contracted Services Coordinator or Service Utilization Assistant. 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 Core and Contracted Services Coordinator for a referral. 3) Referrals for ongoing services (visitation,therapy, home-based, etc.) are reviewed by the Department's Utilization Review Team (URT) prior to the referral end date. 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 can attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Core and Contracted Services Coordinator,the Service Utilization Manager or the Utilization Review Team. 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 one of the abovementioned parties for proper authorization. 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. 18 PY-12-13-CORE-0140 3) If the client receives services over multiple dates,then the client must sign at the time of service for each date (appointment). 4) If a child is receiving services and is unable to sign,then an appropriate person should sign for the child and indicate their relationship to the child (ex.Jane Smith,foster mom,for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7`"of the month following the month of service in order to be processed for payment that month. Billing received after the 7`"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. 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: Tobi Vegter Core and Contracted Services Coordinator WCDHS/Service Utilization Unit Mailing Address: P.O.Box A,Greeley,CO 80632 Physical Address: 315 A North 11th Avenue,Greeley,CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-12-13-CORE-0140 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month/Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAWAAAAAAAAAAAAAIVtAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: Core& Service Contract Coordinator Date 20 � co S o < Zm c $ g 2 2 E ' (D o E 2kk < tu_ =o k okp $ / N 10 a CO /-° S% / SCI 0.1 in / I To - e o ow x @ § Oc co 0 o &q7 >ii / \ k � Ed k- o 0 meO IQO 22 2 ° g R R 2 & ) 2 � CL a I & D U) 4) 2 WI f2 2 7 O to q O < I8@a Q $ ,� SZ 2 0 bcooTo e \ n $ moo co O cii - _ - ' E I- / 0 7 / \ J 2 k [ E2 & 4- 0 t $ 2n « w � P c 2 I ' - - ( J > 2 co) 0) E72k< -J 2 &5o o < -o to R w -C 2 Q $ 2 # E X Gk6k © 2 CO I2 � e co I u) 2 f g k S \ a) $ _ / t2 � w / f k ( / _\ / . 2 < � I- « 9 0E A k \ � 41 ° — / 9 J -- W « ° E c • = � I / $ a- E 2 � % \ � C< co� � tu / k \ a � x S ao 5CCmc m 0 © ) _ \ , / \ C trt\ — �0 15 CIJ 4.1 f E o � .48 I g * 0 as ) E 2 Q f. Ts t ) at ) o / ] C C 743 j - / / / . \ E � F- r = ,I a Z \ . / \ \ { f 4,E } { 0 a . E a U o 1 u { § _ ; § , 01 / LA I 01 2VI § E } } \ I cr z § _ { ) 2 / I ■ } k 2 § \ / C \ o U. / ) ( j E ; i 15 al ; ! eV rti tX � \ 3 _ \ } / § GC - : / e ra E / § \ � § tt 1.1 / . I z Bcs to a _ , % rt i / I . O ' o I ea f 0 > It 4, > 8 - � ., 8 E 2 ' ) \ c 3 5 ) _ % f E \ 4 R ) o ! E u E 04. at / 2 ° 301 00 \ O \ , / / Cl & ' ; 0 at 1 \ k 0 C3 t E Ti; ) • / � � 4 9 | � � LI-ICC \ \ O.© } k / \ \ § } o a 2 E _ / (J ( �_ - 0 \ §k 0) k } a. - 2 � ) - [ ) § at 0- Z \ k » f } ) 2 ) , l 1 PY-12-13-CPS-0093 .,Qf/NA • Lim CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND PERKLEN,INC.,DBA PERKLEN CENTER FOR PSYCHOTHERAPY This Agreement, made and entered into the day of 2012, by and between the Board of Weld County Commissioners,sitting as the Board of Human Services,on behalf of the Weld County Department of Human Services,hereinafter referred to as the"Department"and Perklen, Inc.,dba Perklen Center for Psychotherapy, hereinafter referred to as the"Contractor". WITNESSETH WHEREAS,required approval,clearance,and coordination have been accomplished from and with appropriate agencies;and WHEREAS,the Colorado Department of Human Service has provided Child Welfare Adminstration to the Department for Anger Management/Domestic Violence Evaluation and Treatment;and NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2012 upon proper execution of this Agreement and shall expire May 31,2013 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization,billing and tracking requirements as outlined in Exhibit D"Process Reference Guide",of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B"Payment Schedule,"of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement which will be paid from Child Welfare Administration funding during the duration of this Agreement. 1 O7O/a— a/ PY-12-13-CPS-0093 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for,and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement,CONTRACTOR shall comply with the administrative requirements,cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives,contractual terms,or reporting requirements. In the vent of forfeiture of reimbursement,CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement,CONTRACTOR shall strictly adhere to all applicable Federal and State laws,orders,and all applicable standards, regulations, interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers, documents,tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d-1 et. seq. and its implementing regulation,45 C.F.R. Part 80 et.seq.;and 2 PY-12-13-CPS-0093 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race,creed, color,se,or national origin, be excluded from participation in, be denied the benefits of,or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.Section 794,and its implementing regulations,45 C.F.R. Part 84; and • the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et.seq. and its implementation regulations,45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964;and • the Age Discrimination in Employment Act of 1967;and • the Equal Pay Act of 1963;and • the Education Amendments of 1972;and • Immigration Reform and Control Act of 1986, P.L.99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race,color, National origin,and sex, religion and handicap,including Acquire Immune Deficiency Syndrome(AIDS)or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended,cited above. If necessary,CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute(C.R.S.)26-6-104, requiring criminal background record checks for all employees,CONTRACTORS,and sub-contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services,Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Child Welfare Adminstration funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not,within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,or performing a public (federal, state or local)transaction or contract under a public transaction;violation of federal or state antitrust statues or commission of embezzlement,theft,forgery, bribery,falsification or destruction of records, making false statements,or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity(federal,state,or local)with commission of any of the offenses enumerated in paragraph 12 of this certification;and 3 PY-12-13-CPS-0093 iv. Have not,within a three-year period preceding this Agreement,had one or more public transactions(federal,state, and local)terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.)8-17.5-101,et.seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents,warrants, and agrees that is(a)has verified that it does not employ any illegal aliens,through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security,and(b)otherwise will comply with the requirements of C.R.S.8-17.5-102(2)(6). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S.8-17.5-101,et.seq.,the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S.24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement,CONTRACTOR must confirm that any individual natural person eighteen(18)years of age or older is lawfully present in the United States pursuant to C.R.S.24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is(a)is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b)shall produce one of the forms of identification required by C.R.S.24-76.5-101, et seq., and (c)shall produce one of the forms of identification required by C.R.S.24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review,a Program Improvement Plan(PIP)will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s)identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County,the Board of County Commissioners of Weld County,its officers and employees,shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR, its subcontractor,or their employees,volunteers,or agents while performing duties described in this 4 PY-12-13-CPS-0093 Agreement. CONTRACTOR shall indemnify,defend,and hold harmless Weld County,the Board of County Commissioners of Weld County, its employees,volunteers and agents. Therefore,CONTRACTOR shall provide adequate liability(including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteer,and agents engaged in the performance of the Agreement. Upon request,CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum,CONTRACTOR,shall procure,either personally or through its employer as applicable to the CONTRACTOR'S business,at its own expense, and maintain for the duration of the work,the following insurance coverage. Weld County,Colorado, by and through the Board of County Commissioners of Weld County,its employees and agents,shall be named as additional named insured on the insurance,where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease,covering all employees at work site. • General Liability(PL and PD)(Minimum). o Combined single limit-$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below$500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability(Minimum)for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement,a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that,at the time of entering into this Agreement,it has currently in effect all necessary licenses,approvals, insurance,etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-12-13-CPS-0093 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-12-13-CPS-0093 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 Administrator Name Title For Contractor: Kim Ruybal President Name Title 17. Notice 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: For Contractor: Judy A.Griego, Director Kim Ruybal, President P.O. Box A 1020 8th Street Greeley,CO 80632 Greeley,CO 80631 1970)352-1551 1970)353-8171 18. Litigation 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-12-13-CPS-0093 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld,State of Colorado,to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore,the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement,and all rights of action relating to such enforcement,shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied,of any of the immunities, rights, benefits, protections or other provisions,of the Colorado Governmental immunity Act§§24-10-101 et seq.,as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section,subsection, paragraph,sentence,clause,or phrase of this Agreement is for any reason held or decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph,sentence,clause,and phrase thereof irrespective of the fact that any one or more sections,subsections, paragraphs,sentences,clauses,or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer,member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-12-13-CPS-0093 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. CONTRACTOR shall advise its employees, agents, and sub-contractor, if any,that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees,agents,and sub-contractors, if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees,agents,and subcontractors, if any,sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-12-13-CPS-0093 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-12-13-CPS-0093 IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day, month,and year first above written. A Es Ltle) ATTEST: `^* f.$ARD OF COUNTY COMMISSIONERS 442 i , •� ��LD COUNTY,COLORADO Weld County Clerk to the Board .. ,.� ♦/ ', an P.Conway,Chair AUG 1C152- By: ✓/ L.� a &#_ , LIT�. Deputy Clerk' • the Board APPR AS TO FOR unty Attar ey WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES r 1 By: 1 By: iCe&c - r.X d A.Gri go, e for Contractor 1 � ,q NZ-0(Z Title 11 Q7d/(&- r7/lo ; PY-12-13-CPS-0093 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Anger Management and Domestic Violence evaluation and treatment services to male and female adults and juveniles, including developmentally disabled individuals and same sex, in Weld County,who are 10 years of age or older. 2. If referred for evaluation or assessment,two(2)to three(3)sessions will be needed to complete the requirements of the evaluation or assessment. 3. Following evaluation sessions,CONTRACTOR will pose questions designed to gather basic identifying information,examine the client's mental status/mental health issues,and various history(mental health, family/medical,substance abuse,inpatient/outpatient,current social,and criminal). 4. CONTRACTOR will utilize a variety of psychometric assessment tools that may include the following: - Shipley Institute of Living Scale - Millon Clinical Multiaxial Inventory(MCMI) - Minnesota Multiphasic Personality Inventory-II (MMPI-II) - SASSI-Ill Drug and Alcohol Inventory - Jesness Inventory - State Trait Angry Inventory-II - Violence risk Assessment Guide, Domestic Violence Risk Needs Assessment - Domestic Violence Screening Instrument - Spousal Assault Risk and Assessment - Hare PCL-R. 5. CONTRACTOR will submit a written document outlining client's amenability for treatment, recommendations for treatment,further assessment,and risk to repeat similar behavior. The evaluation will determine the best placement for the client in regards to treatment. CONTRACTOR will provide a copy of the evaluation to the caseworker. 6. Anger Management services will include a minimum of twenty(20)weeks of treatment. 7. CONTRACTOR will follow the minimum expected requirement for the treatment of male,female,and Gay/Lesbian/Bisexual/Transgendered individuals who have been domestically violent as mandated by the Colorado Domestic Violence Offender Management Board(DVOMB). Level A(Low Risk): - Psycho-educational Treatment—One(1)90-minute session per week - 36 week educational curriculum - First treatment plan review within two(2)to three(3) months - Second treatment plan review within two(2)to three(3) months of the first review Level B(Moderate - Open ended psycho-educational treatment—One(1)90 minutes Risk): session per week - 46 week educational curriculum - One a month adjunct therapy required; (a)Substance Abuse Treatment,(b) Individual Session,(c)Skills Group, (d) Healthy Relationship Group,(e) DV Education,(f)Caring Dads Group/Mothers Parenting Group, (g)Victim Speaker, (h)Sex Education, (i) HIV/AIDS Education,or(j)Sexual Abuse and Boundaries 12 PY-12-13-CPS-0093 - First treatment plan review within two(2)to three(3)months - Second treatment plan review within two(2)to three(3) months of the first review Level C(High Risk): - Open ended psycho-educational treatment—One(1)90 minutes session per week - 46 week educational curriculum - One weekly skills group;(a) Healthy Relationship Group,(b)Caring Dads/Mothers Parenting Group, (c)Victim Speaker,(d)Sex Education, (e) HIV/AIDS Education,(f)Sexual Abuse and Boundaries,or(j) DV Education - First treatment plan review within two(2)to three(3) months - Second treatment plan review within two(2)to three(3) months of the first review 8. Individual sessions will only be utilized under one or more of the following circumstances: - The referred client's individual treatment needs cannot be adequately addressed in a group setting. - The client is not currently appropriate for a group setting and requires a limited number of individual sessions to prepare for a group setting. - The client's job requirements make it impossible to attend regularly scheduled group sessions and individual sessions are the only option for the client to comply with their treatment plan. - When assessed for a DV track in which an additional contact is required. 9. CONTRACTOR will submit a discharge summary at the conclusion of services. A standard discharge summary will include the reason the client is being discharged (successful,administrative or negative discharge),treatment history with CONTRACTOR,progress or lack of progress,risk to community and any recommendations for future care and/or treatment. 10. 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. 11. 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. 12. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child of a parent 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. 13. 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. 14. CONTRACTOR will participate in team reviews of ongoing services as needed. These will primarily include staffings and Utilization Review Team(URT)and are not considered billable hours. 13 PY-12-13-CPS-0093 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2,below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31,2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds,or any part thereof, become unavailable as determined by the Department,the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $210.00/Episode(Anger Management/Domestic Violence Evaluation) $70.00/Hour(Anger Management/Domestic Violence Evaluation Hourly Rate-Not to exceed cost of full evaluation.) $575.00/Episode(Domestic Violence Assessment) $144.00/Hour(Domestic Violence Assessment Hourly Rate-Not to exceed cost of full assessment.) $20.00/Hour(Domestic Violence Education) $20.00/Hour(Caring Dads Group) $20.00/Hour(Mothers Parting Group) $37.50/Episode(Standard Group Session) $70.00/Hour(Domestic Violence Impact) $70.00/Hour(Individual Session -In-Office) $85.00/Hour(Individual Session -Off-Site) $90.00/Hour(Family Session) CONTRACTOR may not attempt to collect co-pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co-pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s)indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. 14 PY-12-13-CPS-0093 a. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. 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. c. For Monitored Sobriety services,proof of services rendered shall be a sign-in sheet with client signatures or the test result. 15 PY-12-13-CPS-0093 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS(CFSR) The Child and Family Services Reviews(CFSR)examines child welfare service outcomes in three areas;Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review,a Performance Improvement Program(PIP)will be implemented for the state to enhance services to families. Additionally,the review will assess statewide,systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety,permanency and well-being for our youth. In order to insure continued progress in this area,the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.' The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety,permanency and well-being,followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are,first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats,or the caregivers'protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats, and caregivers are unable or unwilling to provide protection. o Risk is the likelihood(chance, potential, prospect)for parenting behavior that is harmful and destructive to a child's cognitive,social,emotional and/or physical development,and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 16 • PY-12-13-CPS-0093 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 tor their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical,emotional,educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-12-13-CPS-0093 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 from the Core and Contracted Services Coordinator or Service Utilization Assistant. 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 Core and Contracted Services Coordinator for a referral. 3) Referrals for ongoing services (visitation,therapy, home-based, etc.) are reviewed by the Department's Utilization Review Team (URT) prior to the referral end date. 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 can attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Core and Contracted Services Coordinator,the Service Utilization Manager or the Utilization Review Team. 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 one of the abovementioned parties for proper authorization. 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. 18 PY-12-13-CPS-0093 3) If the client receives services over multiple dates,then the client must sign at the time of service for each date(appointment). 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. 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: Tobi Vegter Core and Contracted Services Coordinator WCDHS/Service Utilization Unit Mailing Address: P.O.Box A,Greeley,CO 80632 Physical Address: 315 A North 11th Avenue,Greeley,CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-12-13-CPS-0093 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month/Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. 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Z ro — a u c `oO Q11) E Wc 3 4- W as0 NJ Em Z (0J O N -0 32 O c ` a y' O CT a> Q Q .� N Q 00 l a a ( a0 Ucca) 0 l .- � --- 0 ) \ § $ \ \ — o E $ § f OO \ \ t \ 2 'CI_ % 0 ) § _ b at § - ) 0 j ■ -0 J } � \ / Zu. Ea - � JD Z - E - \ � C al / . ■ f 2 } 70 § cr - 2 0 . I a. vi E z _ k - ) u § ® \ a O U. - f Cr IA o -- E 0 cp , D ) \ \ To \ / / \ $ re -c @ 2I- ) \ / / k 2 ± ._ e \ % § U k « / 9 U ) ) : - / [ La) } x - E § @ ac \ } c J b k { % C - / f _ . � § C > \ LI eV 2 -o \ S / @ } ) ] E o \ o . . § 0 § - 2 k ¢ \ $ ; . ) . -- . . . - o r. / \ _ •- § - i \ ; ; - \ 7. ( \ I I - . _ ; e - , — _ O % I U \ / k - 01 \- B ( ( \ § • O ! § 0. ■ § a - i- & \ U 0 _ \ = \ - ) Z & : c { - § , ° e a ! § § . ) \ } at # / ) 3 a » f va } / k f PY-12-13-CORE-0136 (:),V67//c?.., .) CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND VICTOR H.CORDERO,PSY.D.,P.C. This Agreement,made and entered into the day of ,2O12,by and between the Board of Weld County Commissioners,sitting as the Board of Human Services,on behalf of the Weld County Department of Human Services,hereinafter referred to as the"Department"and Victor H.Cordero, Psy.D.,P.C.,hereinafter referred to as the"Contractor". WITNESSETH WHEREAS, required approval,clearance,and coordination have been accomplished from and with appropriate agencies;and WHEREAS,the Colorado Department of Human Service has provided Core Services to the Department for Mental Health Services;and NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1,2012,upon proper execution of this Agreement and shall expire May 31,2012,unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"of which are attached hereto and incorporated herein by reference 3. Referrals/Billing,/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D"Process Reference Guide",of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B"Payment Schedule,"of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 PY-12-13-CORE-0136 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement,whether In whole or in part,is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for,and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement,CONTRACTOR shall comply with the administrative requirements,cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements,program objectives,contractual terms,or reporting requirements. In the vent of forfeiture of reimbursement,CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations,including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement,CONTRACTOR shall strictly adhere to all applicable Federal and State laws,orders,and all applicable standards, regulations,interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records,papers,documents,tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d-1 et. seq.and its implementing regulation,4S C.F.R.Part 80 et.seq.;and 2 PY-12-13-CORE-0136 • All provisions of Civil Rights Act of 1986 so that no person shall,on the grounds of race,creed, color,se,or national origin, be excluded from participation in,be denied the benefits of,or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973,29 U.S.C.Section 794,and its implementing regulations,45 C.F.R. Part 84;and • the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et.seq.and its implementation regulations,45 C.F.R.Part 91;and • Title VII of the Civil Rights Act of 1964;and • the Age Discrimination in Employment Act of 1967;and • the Equal Pay Act of 1963;and • the Education Amendments of 1972;and • Immigration Reform and Control Act of 1986,P.L.99-603 • 42 C.F.R. Part 2;and all regulations applicable to these laws prohibiting discrimination because of race,color, National origin,and sex, religion and handicap, including Acquire Immune Deficiency Syndrome(AIDS)or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary,CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R.Part 2. 45 C.F.R.Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute(C.R.S.)26-6-104,requiring criminal background record checks for all employees,CONTRACTORS,and sub-contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S.Department of Health and Human Services,Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred,suspended, proposed for debarment,declared ineligible,or voluntarily excluded from covered transaction by a federal department or agency. ii. Have not,within a three-year period preceding this Agreement,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing a public (federal,state or local)transaction or contract under a public transaction;violation of federal or state antitrust statues or commission of embezzlement,theft,forgery, bribery,falsification or destruction of records,making false statements,or receiving stolen property; iii. Are not presently indicted for other otherwise criminally or civilly charged by a government entity (federal,state,or local)with commission of any of the offenses enumerated in paragraph 12 of this certification;and 3 PY-12-13-CORE-0136 iv. Have not,within a three-year period preceding this Agreement, had one or more public transactions(federal,state,and local)terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.)8-17.5-101,et.seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents,warrants, and agrees that is(a)has verified that it does not employ any illegal aliens,through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security,and(b)otherwise will comply with the requirements of C.R.S.8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S. 8-17.5-101,et. seq.,the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S.24-76.5-103(3),if CONTRACTOR receives federal or state funds under this Agreement,CONTRACTOR must confirm that any individual natural person eighteen(18)years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4) if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is(a)is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law,(b)shall produce one of the forms of identification required by C.R.S.24-76.5-101, et seq., and(c)shall produce one of the forms of identification required by C.R.S.24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety,Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review,a Program Improvement Plan(PIP)will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety,Permanency and Well Being. Any CONTRACTOR providing services in the program area(s)identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas,unless otherwise determined by the Department. 9. Insurance Weld County,the Board of County Commissioners of Weld County, its officers and employees,shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR,its subcontractor,or their employees,volunteers,or agents while performing duties described in this 4 PY-12-13-CORE-0136 Agreement. CONTRACTOR shall indemnify,defend,and hold harmless Weld County,the Board of County Commissioners of Weld County, its employees,volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability (including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteer, and agents engaged in the performance of the Agreement. Upon request,CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR, shall procure,either personally or through its employer as applicable to the CONTRACTOR'S business,at Its own expense,and maintain for the duration of the work,the following insurance coverage. Weld County,Colorado,by and through the Board of County 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-12-13-CORE-0136 11. Training CONTRACTOR may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate CONTRACTOR for said training in the form of registration fees,time spent traveling to and from training,attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas CONTRACTOR will,on behalf of its employees and/or officers,accept any subpoena for testimony from the Weld County Attorney's Office by facsimile and will return a waiver of service within 72 business hours. If the Contractor receives a subpoena via facsimile but will only accept personal service,the Contractor will contact the Weld County Attorney's Office immediately at 970-353-5215,x6503,and advise that the subpoena must be personally served. 13. Monitoring and Evaluation CONTRACTOR and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the 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-12-13-CORE-0136 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 Administrator Name Title For Contractor: Victor H.Cordero Psychologist Name Title 17. Notice 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: For Contractor: Judy A.Griego,Director Victor H.Cordero,Psychologist P.O.Box A 2870 North Speer,#240 Greeley,CO 80632 Denver,CO 80211 (970)352-1551 J303)455-9480 18. Litigation 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-12-13-CORE-0136 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld,State of Colorado,to expend funds not otherwise appropriated in each succeeding year,as this Agreement is subject to the availability of funding. Therefore,the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement,and all rights of action relating to such enforcement,shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver,express or implied,of any of the immunities,rights, benefits,protections or other provisions,of the Colorado Governmental immunity Act§§24-10-101 et seq.,as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section,subsection, paragraph,sentence,clause,or phrase of this Agreement is for any reason held or decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection,paragraph,sentence,clause,and phrase thereof irrespective of the fact that any one or more sections,subsections,paragraphs,sentences,clauses,or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer,member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest,direct or indirect,in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest,it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition.During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation,CONTRACTOR shall 8 PY-12-13-CORE-0136 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. CONTRACTOR shall advise its employees,agents, and sub-contractor, if any,that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees,agents,and sub-contractors,if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents,and subcontractors,if any,sign a written confidentiality agreement and shall provide a copy of such agreement to the Department,if requested. 9 PY-12-13-CORE-0136 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-12-13-CORE-0136 IN WITNESS WHEREOF,the parties hereto uted the Agreement as of the day,month,and year first above written. S ilda ATTEST: ,�� ARDOF COUNTY COMMISSIONERS -75 .I ,, ;_. � ELD COUNTY,COLORADO Weld County Clerk to the Board ♦ lr/ ��I Sean P.Conway,Chair By: / ,... .- !� -i AUG 15 2012 Deputy Clerk he Board APP AS TO FOR : Copt Attorney WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES 4,t:crict k Ju .Grieg Director I Contractor Title 11 'C/ ' -aim; PY-12-13-CORE-0136 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide Mental Health Services to individuals and/or families in Weld County referred by the Department. Services include the following: a. Psychological Evaluation—Evaluation includes a comprehensive evaluation of the client utilizing various assessment tools including standardized,objective, projective and otherwise normed instructions,as well as questionnaires, mental status examination and clinical interview. Testing and screening may include,but are not limited to, any of the following instruments;Wechsler Intelligence Scale-III or subtests,Universal Nonverbal Intelligence Test,other tests of cognitive/intellectual ability,Wechsler Abbreviated Scale of Intelligence,various informal cognitive/neuropsychological tasks,Minnesota Multiphasic Personality Inventory-I1(MMPI-II), Personality Assessment Inventory{PAI),Millon Clinical Multiaxial Inventory-Ill (MCMI-III),Millon Adolescent Clinical Inventory(MACI),Parenting Stress Index, Child Abuse Potential Inventory, Beck Scales of Depression and Anxiety,State Trait Anger Expression Inventory,Trauma Symptom Checklist for Children, and other screening/testing assessments. Face-to-face interview and testing time will range from five(5)to seven(7)hours, plus scoring, interpretation,collateral contacts and report generation. b. Psychosexual Evaluation—Evaluation includes a comprehensive evaluation designed to provide clinical,psychosexual,risk assessment and other relevant information in addition to additional input as requested. Evaluation will provide useful response to specific referral questions and will be guided by the Sex Offender Management Board(5OMB)Standards and Guidelines,with the interest of community safety being paramount. c. Interactional Evaluation—Evaluation of parent-child dynamics,family dynamics,capacity to parent and overall parent ability as determined by,but not limited to,in-person observation of the parent or family during visitation with the children,interview with the parent,parenting related questionnaires and collateral contacts. These evaluations can occur at scheduled visitation time at supervising agencies,the evaluator's office,or in the client's home. d. Mental Health Evaluation—Specific evaluation utilized to assess for the presence of specific mental, emotional,behavioral or psychological process. It is not a comprehensive evaluation of personality,global functioning or intellectual capacity. Assessment is completed utilizing screening instruments,symptom checklists,formal mental status examination,and clinical interview,as well as psychological evaluation tools as appropriate. Face-to-face interview and testing will range from three(3)to five(5)hours, plus scoring, collateral contacts and report generation. e. Individual and Family Counseling—Services to assist in identifying barriers to appropriate parenting. Interventions are designed to improve safety of children in the home,assist in stabilizing the home environment and adult/caregiver behaviors,and intervene in order to affect more positive,healthy family dynamics and functioning. 2. Services will be provided by Victor H.Cordero,Psy.D. 12 PY-12-13-CORE-0136 3. CONTRACTOR is bi-lingual (Spanish/English). 4. CONTRACTOR will make at least three(3)attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral(excluding weekends and holidays). CONTRACTOR will document efforts to engage client in referred services. If after three(3)attempts the client does not respond the CONTRACTOR will notify the caseworker and the Core and Service Contract Coordinator immediately. 5. CONTRACTOR will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 6. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any child whom the CONTRACTOR is working with under an active referral. Areas of concern may include, but are not limited to,any physical,emotional,educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 7. CONTRACTOR will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. CONTRACTOR will participate in team reviews of ongoing services as needed. These will primarily include staffings and Utilization Review Team (URT)and are not considered billable hours. 13 PY-12-13-CORE-0136 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2,below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31,2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds,or any part thereof, become unavailable as determined by the Department,the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $800.00/Episode(Mental Health Assessment) $1,000.00/Episode(Interactional Evaluation) S500.00/Person(Additional Charge for Two Parent Interactional Evaluation) $1,200.00/Episode(Psychological or Psychosexual Evaluation) $350.00/Hour(Hourly rate for partially completed evaluations. Not too exceed the full cost of the evaluation.) $100.00/Hour(Individual Therapy) $120.00/Hour(Family Therapy) CONTRACTOR may not attempt to collect co-pays and/or fees for services for which a Department client is responsible,but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co-pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s)indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. 14 PY-12-13-CORE-0136 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services,proof of services rendered shall be a sign-in sheet with client signatures or the test result. 15 PY-12-13-CORE-0136 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS(CFSR) The Child and Family Services Reviews(CFSR) examines child welfare service outcomes in three areas;Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review,a Performance Improvement Program (PIP)will be implemented for the state to enhance services to families. Additionally,the review will assess statewide, systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety,permanency and well-being for our youth. In order to insure continued progress in this area,the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety,permanency and well-being,followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are,first and foremost,protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats,or the caregivers'protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats,and caregivers are unable or unwilling to provide protection. o Risk is the likelihood(chance,potential,prospect)for parenting behavior that is harmful and destructive to a child's cognitive,social,emotional and/or physical development,and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 16 PY-12-13-CORE-0136 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out-of-home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made,in the CONTRACTORs'opinion. • CONTRACTORs should continually assess family relationships(parent/child,sibling/sibling,extended family/child,etc.)and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well-Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents'capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical,emotional,educational and behavioral well-being of the child. When appropriate,CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 17 PY-12-13-CORE-0136 EXHIBIT D PROCESS REFERENCE GUIDE FOR CONTRACTORS Contracted Services Referral/Tracking/Billing Procedures The following procedures apply to all CONTRACTORs regardless of the service being provided, unless otherwise directed 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 from the Core and Contracted Services Coordinator or Service Utilization Assistant. 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 Core and Contracted Services Coordinator for a referral. 3) Referrals for ongoing services (visitation,therapy,home-based,etc.)are reviewed by the Department's Utilization Review Team (URT) prior to the referral end date. 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 can attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Core and Contracted Services Coordinator,the Service Utilization Manager or the Utilization Review Team. 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 one of the abovementioned parties for proper authorization. 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. 18 PY-12-13-CORE-0136 3) If the client receives services over multiple dates,then the client must sign at the time of service for each date(appointment). 4) If a child is receiving services and is unable to sign,then an appropriate person should sign for the child and indicate their relationship to the child (ex.Jane Smith,foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only,should not cross months,and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7`h of the month following the month of service in order to be processed for payment that month. Billing received after the 7th of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online(if applicable to the service provided), 2)the billing documents(Authorization for Contractual Services with original signature and Request for Reimbursement), and 3)Client Verification Form(s) with original signatures. 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: Tobi Vegter Core and Contracted Services Coordinator WCDHS/Service Utilization Unit Mailing Address: P.O.Box A,Greeley, CO 80632 Physical Address: 315 A North 11th Avenue,Greeley,CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 19 PY-12-13-CORE-0136 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services(Program Area): *Service Month/Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAA AAAAA AAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAA AAA AAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT $ Approval: / Core&Service Contract Coordinator Date 20 as \ _ / 5 < I 6 e y a) a) E 4 \ 2 E ® « \ » xA E � o a) '13 mu c 0 �.> / / In k _� , , , , , , , , , , , , , , / k/ j \ \ � \ 6 in / / � \ \ . -0 cu 7 / _�\ k R 2 \ § I [ 0@ % F Os, e o ± 01E333 k0m / ? k 5 ) 7 I EI03 a S 2 ` 2 fE � a7 /• \ \ \ \ a_ I.--- 0 .% _ \ ® ® 2 � \ \ g o omoo m O m , E 0 ° 7f 3 k % H / .0 o 0 a' % « I- R ( kf + � k i / m < W — $ / Tu \ \ a_= 0 \ \t � 2 e q CL 3 % ® < 0 < m0e * \ < -o § \ \ / /, X 2 0 \ 6k © E / Iz � ,_ w 3 m > \ Q $ o # [ � / ( \ ,- a) ' e # o % @o < 7= 0 '- a ) \ \ [ < � CL � — _ / \ / y A 6 0 � - o CC Z 2 ° \ O < E u \ \ \ \ E � m �uf N ee ± 2 � zap \ _ &� o.g C. . § \ i � / 0 0Yfo Q 2 01% \ / - a } o o a { E I o $ o t % % } / \ 2 \ q ( \: cot a ) u f / \ \ tu ± § / j ( % 2 \ { ; \ \ i \ \ \ { E _ ( } k > . . cr E / \ - 7 -z \ \ § / ) / a E _o ) 2 s « q { E _ [ ! \ Cr z• = [ / # \ o « 2 § 21 } esis e > ! - \ ( \ } - % } iti w \ \ ; 0. \ : : \ a \ I Rm ) } _ § - 0 O -a }2 = e — / / Ks § k - § s. § % _ Y. Lij § \ � . § ° EE_c O t _\ ! k S � } \ k E \ } 0 ` L. - } � Z E cu, , $ z ) t t - ' ) / \ t °i \ / § » , ! } \51 2 \ _ \ \ ) } E _ ) ) \ 7 @ f = $ k \ 7 ( / - - a 0. 76.w .. 2 ( \ ( � . - § ) / E . 2 E .\ \ 8 ( e _ -. - c 4 J 8 15 / k c / 0 °7 k \ 2 c ( ( = , 2 E 0- k \ o i za 2f PY-12-13-CORE-0220 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HELENE WURTH This Agreement, made and entered into the day of 2012, by and between the Board of Weld County Commissioners,sitting as the Board of Human Services, on behalf of the Weld County Department of Human Services,hereinafter referred to as the"Department" and Helene Wurth, 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 Foster Parent Consultation;and NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2012 upon proper execution of this Agreement and shall expire May 31, 2013 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking. CONTRACTOR understands and will comply with all aspects of the referral authorization,billing and tracking requirements as outlined in Exhibit D"Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B"Payment Schedule," of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement which will be paid from Core Services funding during the duration of this Agreement. 1 oPe/a—ar ; PY-12-13-CORE-0220 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for,and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement,CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives,contractual terms,or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement,CONTRACTOR shall strictly adhere to all applicable Federal and State laws,orders,and all applicable standards, regulations,interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records,papers, documents,tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d-1 a seq.and its implementing regulation,45 C.F.R. Part 80 et.seq.; and 2 PY-12-13-CORE-0220 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race,creed, color,se,or national origin, be excluded from participation in, be denied the benefits of,or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973,29 U.S.C.Section 794,and its implementing regulations,45 C.F.R. Part 84;and • the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et.seq. and its implementation regulations,45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964; and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963;and • the Education Amendments of 1972; and • Immigration Reform and Control Act of 1986, P.L.99-603 • 42 C.F.R. Part 2; and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin,and sex, religion and handicap,including Acquire Immune Deficiency Syndrome(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible, as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute(C.R.S.) 26-6-104, requiring criminal background record checks for all employees,CONTRACTORS,and sub-contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services, Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Core Services funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred,suspended, proposed for debarment, declared ineligible,or voluntarily excluded from covered transaction by a federal department or agency. H. Have not,within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing a public (federal,state or local)transaction or contract under a public transaction;violation of federal or state antitrust statues or commission of embezzlement,theft,forgery, bribery,falsification or destruction of records, making false statements,or receiving stolen property; Hi. Are not presently indicted for other otherwise criminally or civilly charged by a government entity(federal,state, or local)with commission of any of the offenses enumerated in paragraph 12 of this certification;and 3 PY-12-13-CORE-0220 iv. Have not,within a three-year period preceding this Agreement, had one or more public transactions(federal,state,and local)terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.)8-17.5-101,et.seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents,warrants, and agrees that is(a) has verified that it does not employ any illegal aliens,through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security,and(b)otherwise will comply with the requirements of C.R.S.8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S.8-17.5-101,et. seq.,the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S.24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement,CONTRACTOR must confirm that any individual natural person eighteen (18)years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4)if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor, it hereby sears or affirms under penalty of perjury that is(a)is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law, (b)shall produce one of the forms of identification required by C.R.S.24-76.5-101, et seq., and (c)shall produce one of the forms of identification required by C.R.S.24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review,a Program Improvement Plan(PIP)will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County,the Board of County Commissioners of Weld County, its officers and employees,shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR,its subcontractor, or their employees,volunteers, or agents while performing duties described in this 4 PY-12-13-CORE-0220 Agreement. CONTRACTOR shall indemnify, defend, and hold harmless Weld County,the Board of County Commissioners of Weld County, its employees,volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability(including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteer, and agents engaged in the performance of the Agreement. Upon request,CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum,CONTRACTOR, shall procure,either personally or through its employer as applicable to the CONTRACTOR'S business,at its own expense, and maintain for the duration of the work,the following insurance coverage. Weld County, Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents,shall be named as additional named insured on the insurance,where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease,covering all employees at work site. • General Liability(PL and PD) (Minimum). o Combined single limit-$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than $1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below$500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability(Minimum)for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses,approvals,insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-12-13-CORE-0220 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-12-13-CORE-0220 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 Administrator Name Title For Contractor: Helene Wurth Private Practice Name Title 17. Notice 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: For Contractor: Judy A. Griego, Director Helene Wurth, Private Practice P.O. Box A 4306 Beaver Creek Drive Greeley,CO 80632 Fort Collins,CO 80526 {970)352-1551 {970)631-6235 18. Litigation 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-12-13-CORE-0220 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld,State of Colorado,to expend funds not otherwise appropriated in each succeeding year,as this Agreement is subject to the availability of funding. Therefore,the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement,and all rights of action relating to such enforcement,shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied,of any of the immunities,rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act§§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph,sentence, clause,or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph,sentence,clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs,sentences, clauses,or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest,direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-12-13-CORE-0220 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. CONTRACTOR shall advise its employees,agents, and sub-contractor, if any,that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees, agents, and sub-contractors,if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees,agents, and subcontractors,if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-12-13-CORE-0220 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-12-13-CORE-0220 IN WITNESS WHEREOF,the parties hereto have uted the Agreement as of the day, month, and year first above written. ATTEST: D OF COUNTY COMMISSIONERS 46% ',*¼ E1 COUNTY,COLORADO Weld County Clerk to the Board an P. Conway, Chair By: �i�, . .. !�!! l� AUG 15 2012 Deputy Clerk( the Board AS TO FQR County A rney WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES By: By: J d A.Gri g , Direct r Contractor ( iJa e Prot OA CQ Title 11 aoia-a/ PY-12-13-CORE-0220 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide face-to-face consultation for children and youth residing in Weld County foster homes within Weld County, as referred by the Department. The goal of the program is to enhance and improve the quality of care being provided to Weld County's children and youth. 2. CONTRACTOR will work collaboratively with children,foster parents, caseworkers,foster care coordinators and other service providers to identify and address issues,in a solution-focused manner,to address issues that could potentially disrupt placements. 3. CONTRACTOR will make recommendations to foster family following assessment of the child. CONTRACTOR will document recommendations and follow through of foster family with regard to recommendations. 4. CONTRACTOR will assess foster families abilities and capacity on an ongoing basis to appropriately care for the foster children in their home and report this information on a monthly basis to the Department. 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. S. 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. 9. CONTRACTOR will participate in team reviews of ongoing services as needed. These will primarily include staffings and Utilization Review Team (URT)and are not considered billable hours. 12 PY-12-13-CORE-0220 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part,is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department,the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $100.00/Hour(Foster Parent Consultation) CONTRACTOR may not attempt to collect co-pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co-pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s)indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. b. For Monitored Sobriety services, proof of services rendered shall be a sign-in sheet with client signatures or the test result. 13 PY-12-13-CORE-0220 EXHIBIT C CHILD and FAMILY SERVICES REVIEWS(CFSR) The Child and Family Services Reviews(CFSR)examines child welfare service outcomes in three areas;Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitors progress over time. Following the review,a Performance Improvement Program(PIP)will be implemented for the state to enhance services to families. Additionally,the review will assess statewide,systemic factors to determine if the systems necessary to achieve positive outcomes for families are in place. All agencies that contract to provide service to families and children in Weld County must continually strive for positive outcomes in the areas of safety, permanency and well-being for our youth. In order to insure continued progress in this area,the Department is requiring CONTRACTORS to comply with a standard assessment and reporting system which will address these three areas.* The Department is requesting that CONTRACTOR reports include observations and recommendations regarding clients in a way that specifically addresses the areas of safety, permanency and well-being. Below are the specific outcomes that will be assessed by the CFSR in the areas of safety, permanency and well-being,followed by specific considerations and tasks which must be addressed by the Department contracted CONTRACTORs. Safety Outcomes CFSR Outcome Measures Safety 1 Children are,first and foremost, protected from abuse and neglect. Safety 2 Children are safely maintained in their homes whenever possible and appropriate. Considerations for the Department's CONTRACTORs • CONTRACTORs should always consider the following definitions regarding child safety when assessing families. o Children are considered safe when there are no present dangers or impending danger threats,or the caregivers' protective capacities control existing threats. o Children are considered unsafe when they are vulnerable to present or impending danger threats,and caregivers are unable or unwilling to provide protection. o Risk is the likelihood (chance, potential, prospect)for parenting behavior that is harmful and destructive to a child's cognitive,social,emotional and/or physical development,and those with parenting responsibility are unwilling or unable to behave differently. • Monthly reports should continually document an assessment of risk and safety concerns and the interventions that are being offered by the CONTRACTOR to ameliorate those concerns. • Monthly reports should make recommendations regarding services and/or safety measures that the CONTRACTOR believes should be implemented to insure safety of the child(ren). • CONTRACTORs must specifically document efforts to engage families in services and to control for safety. 14 PY-12-13-CORE-0220 Permanency Outcomes CFSR Outcome Measures Permanency 1 Children have permanency and stability in their living situations. Permanency 2 The continuity of family relationships and connections is preserved for children. Considerations for the Department's CONTRACTORs: • CONTRACTOR reports should always note the primary permanency goal for the child and document how interventions are working toward achieving that goal. • CONTRACTOR reports must indicate progress toward achieving the permanency goal and should make specific recommendations regarding how the continuation of the service may assist in achieving the goal. • CONTRACTORs should continually provide recommendations about whether any out-of-home placement continues to be appropriate and should make recommendations regarding when changes in this area should be made,in the CONTRACTORs'opinion. • CONTRACTORs should continually assess family relationships(parent/child,sibling/sibling,extended family/child,etc.) and should report any concerning relationship issues which may be a barrier to achieving permanency. CONTRACTORs should document ongoing efforts to resolve those issues and/or make recommendations regarding additional services that may be required to address relationship issues. • CONTRACTORs must document specific time frames when recommending ongoing services and/or recommending changes to services and/or placements. Child and Family Well-Being Outcomes CFSR Outcome Measures Well Being 1 Families have enhanced capacity to provide for their children's needs. Well Being 2 Children receive appropriate services to meet their educational needs. Well Being 3 Children receive adequate services to meet their physical and mental health needs. Considerations for the Department's CONTRACTORS: • CONTRACTORs must engage in ongoing assessments of the parents' capacity to appropriately care for their children and whether or not the service being provided continues to be appropriate. This must be clearly documented in monthly reports. • CONTRACTORs should specifically detail areas of continued concern within the family and make recommendations regarding whether that CONTRACTOR's service continues to be appropriate. Reports should also document what barriers may be impeding progress. • CONTRACTORs should document any and all observed concerns regarding any child with whom the CONTRACTOR is working. This should include concerns regarding physical,emotional, educational and behavioral well-being of the child. When appropriate, CONTRACTORs should make recommendations regarding evaluations and/or additional services that may address these concerns. *Standardized reports will be provided and should be utilized by all agencies providing ongoing services to the Department's families unless otherwise noted. 15 PY-12-13-CORE-0220 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 from the Core and Contracted Services Coordinator or Service Utilization Assistant. 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 Core and Contracted Services Coordinator for a referral. 3) Referrals for ongoing services (visitation, therapy, home-based, etc.) are reviewed by the Department's Utilization Review Team (URT) prior to the referral end date. 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 can attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Core and Contracted Services Coordinator,the Service Utilization Manager or the Utilization Review Team. 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 one of the abovementioned parties for proper authorization. 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. 16 PY-12-13-CORE-0220 3) If the client receives services over multiple dates, then the client must sign at the time of service for each date (appointment). 4) If a child is receiving services and is unable to sign,then an appropriate person should sign for the child and indicate their relationship to the child (ex.Jane Smith, foster mom, for Jimmy Jones). 5) The Client Verification Form should track services for one calendar month only, should not cross months, and must be submitted with that month's billing. Billing: 1) All billing must be submitted by the 7th of the month following the month of service in order to be processed for payment that month. Billing received after the 7`h of the month may result in forfeiture of payment as noted in the Agreement. 2) All payments are contingent upon receiving a complete and accurate billing. A complete billing should include a 1) monthly progress report submitted online (if applicable to the service provided), 2) the billing documents (Authorization for Contractual Services with original signature and Request for Reimbursement), and 3) Client Verification Form(s) with original signatures. 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: Tobi Vegter Core and Contracted Services Coordinator WCDHS/Service Utilization Unit Mailing Address: P.O. Box A,Greeley, CO 80632 Physical Address: 315 A North 11th Avenue,Greeley,CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 17 PY-12-13-CORE-0220 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month/Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. 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Z O < c \ k/ / / f \ 0- k S 2 e.2 $ $ a • / J � o_ o QI \ a • :11 ao _ c ) 2 0 . .2 all C § £ - \ ) / ( o u ce a re O I i § 2 / u ` C \ - § ) \ % c E ) �0J 'CI \ / E -13 � $ 0J § ) \ } % § ± f ,..9 . f | % | z § 0C fo ] 7 {o § 2 \ — 2 t \ \ 0 § \ ) C k 2 F- d E I i " 4 ill M ■ § ) ER I- 0 6 ru ■ a> S ? ) - ; , 0.1 _ § \ .- d1 / [ e ® � E t o ce \ _ k N § » ° • Cl ± \ \ k fa j 0 / ) i / b - C / C O ' I j � � \ 45 _3.- k } } \ E ) % tli k ) ` .0 - / E § f f ; = a § . « C \ 0J L } La C f Q ] { 0 § § 2 O01 r. 0 u . o \ a f.2. } o / % a . _ . \ CC g �_ E ® \ \) I -! f \ 8 ( - � k / E] a ° z ' / S 2 k % § § \ | § § ' - \ Z \ _ O. ) }) '� - f PY-12-13-HS-0044 12�it., CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HELENE WURTH This Agreement, made and entered into the day of ,2012, by and between the Board of Weld County Commissioners, sitting as the Board of Human Services,on behalf of the Weld County Department of Human Services,hereinafter referred to as the"Department"and Helene Wurth,hereinafter referred to as the "Contractor". WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies;and WHEREAS,the Colorado Department of Human Service has provided Child Welfare Adminstration to the Department for Home Studies and Relinquishment Counseling; and NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows: 1. Term This Agreement shall become effective on June 1, 2012 upon proper execution of this Agreement and shall expire May 31, 2013 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the CONTRACTOR to any person(s)eligible for child protection services in compliance with Exhibit A"Scope of Services,"of which are attached hereto and incorporated herein by reference 3. Referrals/Billing/Tracking CONTRACTOR understands and will comply with all aspects of the referral authorization, billing and tracking requirements as outlined in Exhibit D"Process Reference Guide", of which are attached hereto and incorporated herein by reference. 4. Payment Payment shall be made on the basis of Exhibit B"Payment Schedule,"of which are attached hereto and incorporated herein by reference. "Payment Schedule"shall establish the maximum reimbursement which will be paid from Child Welfare Administration funding during the duration of this Agreement. 1 GOd/& are PY-12-13-HS-0044 a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit 0 of this Agreement in accordance with criteria established by the Department. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7`b day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. b. Payment pursuant to this Agreement,whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. c. The Department shall not be billed for,and reimbursement shall not be made for time involved in activities outside of those defined in Exhibit A and authorized by the Department. Work performed prior to the execution of this Agreement and prior to an authorized referral shall not be reimbursed or considered part of this Agreement. 5. Financial Management At all times from the effective date of Agreement until completion of this Agreement, CONTRACTOR shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must confirm to the Single Audit Act of 1984 and OMB Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit A and Exhibit B: a. CONTRACTOR shall provide proper monthly invoices and itemization of services preformed for costs incurred in the performance of this Agreement. b. The Department may withhold any payment if CONTRACTOR has failed to comply with the Financial Management Requirements, program objectives,contractual terms, or reporting requirements. In the vent of forfeiture of reimbursement, CONTRACTOR may appeal such circumstance to the Director of Human Services. The decision of the Director of Human Services shall be final. 7. Compliance with Applicable Laws CONTRACTOR shall abide by all applicable laws and regulations, including, but not limited to the following: a. Compliance with Applicable Laws At all times during the performance of this Agreement, CONTRACTOR shall strictly adhere to all applicable Federal and State laws,orders,and all applicable standards, regulations,interpretations or guidelines issued pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records, papers,documents,tapes and any other materials have been or may hereafter be established which relate to the Agreement. CONTRACTOR acknowledges that the following laws are included: • Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-1 et.seq. and its implementing regulation,45 C.F.R. Part 80 et.seq.; and 2 PY-12-13-HS-0044 • All provisions of Civil Rights Act of 1986 so that no person shall, on the grounds of race,creed, color,se,or national origin, be excluded from participation in, be denied the benefits of,or be otherwise subjected to discrimination under the is approved Agreement. • Section 504 of the Rehabilitation Act of 1973,29 U.S.C.Section 794, and its implementing regulations,45 C.F.R. Part 84; and • the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et. seq.and its implementation regulations,45 C.F.R. Part 91; and • Title VII of the Civil Rights Act of 1964;and • the Age Discrimination in Employment Act of 1967; and • the Equal Pay Act of 1963; and • the Education Amendments of 1972;and • Immigration Reform and Control Act of 1986, P.L.99-603 • 42 C.F.R. Part 2;and all regulations applicable to these laws prohibiting discrimination because of race, color, National origin,and sex,religion and handicap,including Acquire Immune Deficiency Syndrome(AIDS)or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended,cited above. If necessary,CONTRACTOR and Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74,Appendix G 9,which requires that affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies, equipment,construction and services. This assurance is given in consideration of and for the purpose of obtaining any and all Federal and/or State financial assistance. • Colorado Revised Statute(C.R.S.)26-6-104, requiring criminal background record checks for all employees, CONTRACTORS,and sub-contractors. CONTRACTOR is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services,Office for Civil Rights. b. CONTRACTOR assures that it will fully comply with all other applicable federal and state laws which may govern the ability of the Department to comply with the relevant funding requirements. CONTRACTOR understands that the source of funds to be used under this Agreement is Child Welfare Adminstration funds. c. CONTRACTOR assures and certifies that it and its principals: i. Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily excluded from covered transaction by a federal department or agency. H. Have not,within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,or performing a public (federal,state or local)transaction or contract under a public transaction;violation of federal or state antitrust statues or commission of embezzlement,theft,forgery, bribery,falsification or destruction of records, making false statements,or receiving stolen property; Hi. Are not presently indicted for other otherwise criminally or civilly charged by a government entity(federal,state, or local)with commission of any of the offenses enumerated in paragraph 12 of this certification; and 3 PY-12-13-HS-0044 iv. Have not,within a three-year period preceding this Agreement, had one or more public transactions(federal,state,and local)terminated for cause or default. d. CONTRACTOR certifies that it shall comply with the provisions of Colorado Revised Statutes (C.R.S.)8-17.5-101,et. seq. CONTRACTOR shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter in to a contract with a subcontractor that fails to certify to the CONTRACTOR that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. CONTRACTOR represents,warrants, and agrees that is(a) has verified that it does not employ any illegal aliens,through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b)otherwise will comply with the requirements of C.R.S.8-17.5-102(2)(b). CONTRACTOR shall comply with all reasonable requests made in the course of an investigation under C.R.S.8-17.5-102 by the Colorado Department of Labor and Employment. If CONTRACTOR fails to comply with any requirements of this provision or C.R.S.8-17.5-101, et. seq., the Department may terminate this Agreement for breach and CONTRACTOR shall be liable for actual and consequential damages to the Department. Except where exempted by federal law and except as provided in C.R.S.24-76.5-103(3), if CONTRACTOR receives federal or state funds under this Agreement,CONTRACTOR must confirm that any individual natural person eighteen (18)years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-103(4)if such individual applies for public benefits provided under this Agreement. If CONTRACTOR operates as a sole proprietor,it hereby sears or affirms under penalty of perjury that is(a)is a citizen of the United State or is otherwise lawfully present in the United States pursuant to federal law,(b)shall produce one of the forms of identification required by C.R.S.24-76.5-101, et seq., and (c)shall produce one of the forms of identification required by C.R.S.24-76.5-103 prior to the effective date of this Agreement. 8. Compliance with Child and Family Services Review The Child and Family Services Review(CFSR)examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome,data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review,a Program Improvement Plan(PIP)will be implemented for the state to enhance services to families. Any CONTRACTOR providing services under this Agreement to families and children referred by the Department will continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Any CONTRACTOR providing services in the program area(s) identified by the Department is required to comply with the standard assessment and reporting system set forth in Exhibit C which will address the aforementioned three areas, unless otherwise determined by the Department. 9. Insurance Weld County,the Board of County Commissioners of Weld County, its officers and employees,shall not be held liable for injuries or damages caused by any negligent acts or omissions of CONTRACTOR,its subcontractor,or their employees,volunteers,or agents while performing duties described in this 4 PY-12-13-HS-0044 Agreement. CONTRACTOR shall indemnify, defend,and hold harmless Weld County,the Board of County Commissioners of Weld County,its employees,volunteers and agents. Therefore, CONTRACTOR shall provide adequate liability(including professional liability insurances where necessary)and worker's compensation insurances for all its employees,volunteer,and agents engaged in the performance of the Agreement. Upon request,CONTRACTOR shall provide the Department with the acceptable evidence that such coverage is in effect. At a minimum, CONTRACTOR,shall procure,either personally or through its employer as applicable to the CONTRACTOR'S business,at its own expense, and maintain for the duration of the work,the following insurance coverage. Weld County,Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance,where permissible by the insurance CONTRACTOR. • Standard Workman's Compensation and Employer's Liability. o As required by State statute including occupational disease,covering all employees at work site. • General Liability(PL and PD) (Minimum). o Combined single limit-$500,000.00 written on an occurrence basis. o Any aggregate limit will not be less than$1 million ($1,000,000.00). o CONTRACTOR must purchase additional insurance if claims reduce the annual aggregate below$500,000.00 o State of Colorado to be named as additional insured on each comprehensive general liability policy. o Certificate of Insurance to be provided to Weld County. o Insurance shall include provision preventing cancellation without 60 days prior notice by certified mail to Weld County. • Automobile Liability(Minimum)for any CONTRACTOR transporting children or any party to whom Department services are being provided. • Additional coverage may be required in specific program areas. For any insurances that are required by this Agreement, a completed Standard Certificate of Insurance shall be provided to the Department by the Contractor prior to the start of any Agreement. 10. Certification CONTRACTOR certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses,approvals, insurance, etc.,required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 5 PY-12-13-HS-0044 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-12-13-HS-0044 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 Administrator Name Title For Contractor: Helene Wurth Private Practice Name Title 17. Notice 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: For Contractor: Judy A.Griego, Director Helene Wurth, Private Practice P.O. Box A 4306 Beaver Creek Drive Greeley,CO 80632 Fort Collins, CO 80526 {970)352-1551 {970)631-6235 18. Litigation 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-12-13-HS-0044 19. Termination This Agreement may be terminated at any time by either party giving thirty(30)days written notice to the individuals identified in paragraph 18. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld,State of Colorado,to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore,the Department may terminate this Agreement at any time if the source of funding for the services made available to the CONTRACTOR is not longer available to the Department. CONTRACTOR reserves the right to suspend services to clients if funding is no longer available. 20. No Third Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement,shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied,of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental immunity Act§§24-10-101 et seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section,subsection, paragraph, sentence,clause,or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph,sentence, clause,and phrase thereof irrespective of the fact that any one or more sections,subsections, paragraphs,sentences,clauses,or phrases might be declared to be unconstitutional or invalid. 23. Improprieties No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest,direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a CONTRACTOR with the Department when the CONTRACTOR also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest,it is not necessary for the CONTRACTOR to gain from knowledge of these opposing interests. It is only necessary that the CONTRACTOR know that the two relationships are in opposition. During the term of the Agreement, CONTRACTOR shall not enter any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, CONTRACTOR shall 8 PY-12-13-HS-0044 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. CONTRACTOR shall advise its employees, agents, and sub-contractor,if any,that they are subject to these confidentiality requirements. CONTRACTOR shall provide its employees,agents,and sub-contractors, if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. CONTRACTOR shall have its employees, agents,and subcontractors, if any,sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 9 PY-12-13-HS-0044 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-12-13-HS-0044 IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: '� s° L®S BOARD OF COUNTY COMMISSIONERS ELD COUNTY,COLORADO Weld County Clerk to the Board 461 1l-t`J^= 1. can P.Conway,ChairCY— By: /I iv � �%. I AUG 15 2012 Deputy Clerk t he Board APPRO AS FO Cou t orney WELD COUNTY DEPARTMENT CONTRACTOR: OF HUMAN SERVICES I�` (! (� � �\ By: • W By: d]�.�cti)C. ll�"Q`n �lN Ju y .Gri , Director Contractor Pry 1r6-t bra l CC- Title 11 CPC/O? -are PY-12-13-HS-0044 EXHIBIT A SCOPE OF SERVICES 1. CONTRACTOR will provide home study and relinquishment counseling services for families within Weld County,as referred by the Department. 2. CONTRACTOR utilizes the Structured Analysis Family Evaluation(SAFE)tool developed by the Consortium of Children. CONTRACTOR is SAFE certified and on the State's approved home study vendor list. CONTRACTOR also is certified as a SAFE supervisor. 3. CONTRACTOR will attend SAFE Refresher training during the term of this contract. 4. CONTRACTOR will ensure that all studies are completed utilizing the most up-to-date forms and templates as found on www.consortforkids.org or www.SAFEhomestudy.org. S. All services will be provided by Helene Wurth, BSW. 6. CONTRACTOR will complete a Department of Motor Vehicle background check at no additional charge. All CBI,FBI and LexisNexis background check information will be completed by the Department, unless otherwise directed by the Department. 7. CONTRACTOR will submit a completed home study to the Department with their billing within 60 days of receipt of the home study referral. A complete home study will include the study in SAFE format, background check information,SAFE questionnaires completed by the applicants, references and all other original documents submitted by the home study applicant. 8. Relinquishment counseling services will be provided to all adult individuals referred by the Department, as well as associated children 12 years of age and older,utilizing the required State format. CONTRACTOR will submit a written report and the appropriate affidavits and interrogatories. 9. CONTRACTOR will document in detail any and all observed or verbalized concerns regarding any specific Weld County home. Areas of concern may include,but are not limited to,any physical,emotional, educational or behavioral issues. Child abuse must be reported immediately per law. 12 PY-12-13-HS-0044 EXHIBIT B PAYMENT SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse Contractor in consideration for the work and services performed under this Agreement at the rate specified in Paragraph 2,below. The total amount to be paid to Contractor during the term of this Agreement shall be reported by the Department in Trails after May 31, 2013. Expenses incurred by Contractor prior to the term of this agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement,whether in whole or in part,is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds,or any part thereof,become unavailable as determined by the Department,the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services $950.00/Episode(Full Home Study) $450.00/Episode(Updated Home Study) $200.00/Person(Additional Adult) $50.00/Hour(Cancellation Home Study) $100.00/Hour(Relinquishment Counseling) $35.00/Hour(Interpretive Services) CONTRACTOR may not attempt to collect co-pays and/or fees for services for which a Department client is responsible,but which a particular client refuses or fails to pay. CONTRACTOR will collect any applicable sliding scale co-pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers CONTRACTOR shall prepare and submit monthly itemized voucher and certify that services authorized were provide on the date(s)indicated and the charges made were pursuant to the terms and conditions of Exhibit A and Exhibit D. CONTRACTOR shall submit all itemized monthly billings to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. a. CONTRACTOR shall submit an itemized monthly bill to the Department for all costs incurred and services provided pursuant to Exhibit A and Exhibit D of this Agreement in accordance with criteria established by the Department. 13 PY-12-13-HS-0044 b. For Monitored Sobriety services, proof of services rendered shall be a sign-in sheet with client signatures or the test result. 14 PY-12-13-HS-0044 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-12-13-HS-0044 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-12-13-HS-0044 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 from the Core and Contracted Services Coordinator or Service Utilization Assistant. 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 Core and Contracted Services Coordinator for a referral. 3) Referrals for ongoing services (visitation,therapy, home-based, etc.)are reviewed by the Department's Utilization Review Team (URT) prior to the referral end date. 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 can attend in person or via phone if more convenient. 4) Any and all modifications to an authorized referral can only be approved by the Core and Contracted Services Coordinator,the Service Utilization Manager or the Utilization Review Team. 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 one of the abovementioned parties for proper authorization. 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. 17 PY-12-13-HS-0044 3) If the client receives services over multiple dates,then the client must sign at the time of service for each date (appointment). 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. 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: Tobi Vegter Core and Contracted Services Coordinator WCDHS/Service Utilization Unit Mailing Address: P.O. Box A,Greeley,CO 80632 Physical Address: 315 A North 11th Avenue,Greeley,CO 80631 4) Final remittance will be provided by the Weld County Department of Human Services Fiscal Office. 18 PY-12-13-HS-0044 WELD COUNTY DEPARTMENT OF HUMAN SERVICES AUTHORIZATION FOR CONTRACTUAL SERVICES TO BE COMPLETED BY CONTRACTOR: Date: CONTRACTOR: Billing Contact: Phone Number: Address: Description of Services (Program Area): *Service Month/Year: Charges: $ *Month/Year services were provided. I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE(S) INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES. Printed Name of Signer CONTRACTOR Signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: AMOUNT AUTHORIZED FOR PAYMENT: $ Approval: / Core&Service Contract Coordinator Date 19 • •�' a) O Q O a) E. 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