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Home My WebLink About20122312.tiff MEMORANDUM 1861 ' -, DATE: September 27, 2012 liX T E \ OT : Sean P Conway, Chair, Weld County Board of Co mi Toners TY (/� a e / " -_ _COUNTY FROM: Judy A. Griego, Director, Human SBrvi� s epa e RE: Agreements to Purchase Out-of-Home t?acernent Services between the Weld County Department of Human Services and Various Providers to be Placed on the Consent Agenda Enclosed for Board approval are Agreements to Purchase Out-of-Home Placement Services between the Department and Various Providers. These Agreements were reviewed under the Board's Pass-Around Memorandum dated August 8, 2012, and approved for placement on the Board's Consent Agenda. Below are the major provisions of the attached Agreements: No. Facility Name/Term Facility Type/Location 1 A Kidz Hope Homes Inc. Child Placement Agency Services July 1,2012—June 30, 2013 Group Home/Group Center Care Colorado Springs, Colorado 2 A.M. Group Home Group Home/Group Center Care July I, 2012—June 30, 2013 Platteville, Colorado 3 Alternative Homes For Youth Residential Child Care Facility July I, 2012—June 30, 2013 Dacono, Colorado 4 Arapahoe House Residential Child Care Facility July 1, 2012—June 30, 2013 Thornton, Colorado 5 Attention Homes Residential Child Care Facility July 1,2012—June 30, 2013 Boulder, Colorado 6 C& M Group Home Group Home/Group Center Care July 1, 2012—June 30, 2013 Greeley, Colorado 7 Cathedral Home for Children Residential Child Care Facility July 1, 2012—June 30, 2013 Laramie, Wyoming 8 Commonworks D.B.A. Synthesis Child Placement Agency Services July 1, 2012—June 30, 2013 Child Residential Habilitation Program Arvada, Colorado 9 Cornell Corrections of Texas, Inc. Residential Child Care Facility DBA Hector Garza Center San Antonio, Texas July 1, 2012—June 30, 2013 10 Denver Children's Home Residential Child Care Facility July 1, 2012—June 30, 2013 Denver, Colorado II Devereux Cleo Wallace Residential Child Care Facility N July 1, 2012—June 30, 2013 Westminster, Colorado M 12 El Pueblo Boys' and Girls' Ranch Residential Child Care Facility N July 1,2012—June 30, 2013 Pueblo, Colorado N o 13 Evergreen Group Home Group Home/Group Center Care N July 1, 2012—June 30, 2013 Longmont, Colorado 14 Excelsior Youth Centers Residential Child Care Facility July 1, 2012—June 30, 2013 Aurora, Colorado 15 Families First Children's Treatment Center Residential Child Care Facility July 1,2012—June 30,2013 Denver, Colorado g- 029-.0190/? r- 3o /a 16 Frontier Family Services Child Placement Agency Services July I,2012—June 30, 2013 Group Home/Group Center Care Longmont, Colorado 17 Hope & Home Child Placement Agency Services July 1, 2012—June 30, 2013 Colorado Springs, Colorado 18 Imagine Child Placement Agency Services July 1, 2012—June 30, 2013 Child Residential Habilitation Program Lafayette, Colorado 19 Jefferson Hills Residential Child Care Facility July 1, 2012—June 30, 2013 Lakewood, Colorado 20 Kids Crossing Child Placement Agency Services July 1, 2012—June 30, 2013 Group Home/Group Center Care Colorado Springs, Colorado 21 Kids Resource Network of Colorado Springs Child Placement Agency Services July 1, 2012—June 30, 2013 Colorado Springs, Colorado 22 Lutheran Family Services Rocky Mountains Child Placement Agency Services July 1, 2012—June 30, 2013 Denver, Colorado 23 Maple Star Colorado Child Placement Agency Services July I, 2012—June 30, 2013 Group Home/Group Center Care Denver, Colorado 24 Marie Alirez Group Home Group Home/Group Center Care July 1, 2012—June 30, 2013 Greeley, Colorado 25 Michael Alirez Group Home Group Home/Group Center Care July 1, 2012—June 30, 2013 Greeley, Colorado 26 Mountain Crest Poudre Valley Health Care Inc. Residential Child Care Facility D/B/A Poudre Valley Hospital Fort Collins, Colorado July 1, 2012—June 30,2013 27 New Start Youth Services LLC Child Placement Agency Services July 1, 2012—June 30, 2013 Pueblo, Colorado 28 Parker Personal Care Homes Inc. Child Placement Agency Services July 1, 2012—June 30, 2013 Child Residential Habilitation Program Arvada, Colorado 29 PSI Cedar Springs Hospital, Inc. Psychiatric Residential Treatment Facility July 1, 2012—June 30, 2013 Colorado Springs, Colorado 30 Quality Life Services LLC Child Placement Agency Services July 1, 2012—June 30, 2013 Child Residential Habilitation Program Broomfield, Colorado 31 Reflections For Youth, Inc. Residential Child Care Facility July 1, 2012—June 30, 2013 Berthoud, Colorado 32 Rocky Mountain Kids Child Placement Agency Services July 1, 2012—June 30, 2013 Group Home/Group Center Care Colorado Springs, Colorado 33 Roundup Fellowship Child Residential Habilitation Program July 1, 2012—June 30, 2013 Group Home/Group Center Care Residential Child Care Facility Denver, Colorado 34 Savio House Residential Child Care Facility July 1, 2012—June 30,2013 Denver, Colorado 35 Shiloh House Residential Child Care Facility July 1, 2012—June 30, 2013 Littleton, Colorado 36 Smith Agency Inc. Child Placement Agency Services July 1, 2012—June 30,2013 Child Residential Habilitation Program Group Home/Group Center Residential Child Care Facility Aurora, Colorado 37 Special Kids Special Families Child Placement Agency Services July 1, 2012—June 30, 2013 Child Residential Habilitation Program Colorado Springs, Colorado 38 Tennyson Center for Children Residential Child Care Facility July 1, 2012—June 30,2013 Denver, Colorado 39 Third Way Center Residential Child Care Facility July 1, 2012—June 30, 2013 Denver, Colorado 40 Whimspire CPA Child Placement Agency Services July 1, 2012—June 30, 2013 Colorado Springs, Colorado If you have any questions, give me a call at extension 6510. AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A Z CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this day of Ara between the Weld County Department of Social/Human Services herein fter called "County" and A Kidz Hope Homes Inc., 1401 W Colorado Ave, Colorado Springs, CO 80904, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with A Kidz Hope Homes Inc.. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible,permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition,psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source,the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the WELD COUNTY BOARD ` � 1 / �` OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY ' a• cif DEPARTMENT OF W° "II HUMAN SERVICES By:r i 2Yy et. . 40 7 IO%r'i:y: 6j — Deputy erk to the Board Chair ignature Protein AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT A Kidz Hope Homes Inc. OF HUMAN SERVICES 1401 W Colorado Ave Colorado Springs, CO 80904 By: By: __ _ J- - o my i ector's r des' ee's) irector's (or designee's) gnature i aturk d Dat and Date 11 at n/01- SS-23A Revised 2/12 (90/at � AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this /A day of a 1, ..26/s between the Weld County Department of Social/Human Services hereinafter called"County" and A.M. Group Home, 509 N Sholdt Dr, Platteville, CO 80651, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with A.M. Group Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 �� f NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 r r 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition,psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent,provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time,to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 • financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to th- :1y. "+w WELD COUNTY BOARD S' Las. OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY • t O kti � DEPARTMENT OF HUMAN SERVICES By I�// / /, . ��. . ,/ BY: O Deput 1erk to the Board Chair Signature Protem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT A.M. Group Home OF HUMAN SERVICES 509 N Sholdt Dr Platteville, CO 80651 By: By: ICED l/L_ Co Direc is (or de nee's) Director's (or designee's) Signature Si a tire and ate and Date 11 SS-23A Revised 2/12 C20/6-1- 3A AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A 2012 AUG 13 A 11. 58 ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ® RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) El OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this ,,(h day of /b /02o/1 between the Weld County Department of Social/Human Services herein fter called"County" and Alternative Homes For Youth, PO Box 9, Dacono, CO 80514, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Alternative Homes For Youth. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 t/c -a3/4 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services,the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 7/I7 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2R2 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs)within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk tot to +w. WELD COUNTY BOARD 4 OF SOCIAL SERVICESTHE ,ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: By: Offt /7e Deputy erk to the Board Chair Signature Protein AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Alternative Homes For Youth OF HUMAN SERVICES PO Box 9 Dacono, CO 80514 By: By: C i ty D' c or's (or signee ) Direc or's or designee's) Signature S ture d Date and Dat 11 SS-23A Revised 2/12 c>2O/O7-(2-9/ AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of ei< ,/.2 between the Weld County Department of Social/Human Services herei after called "County" and Arapahoe House, 8801 Lipan St, Thornton, CO 80260, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Arapahoe House. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 070107-c23/0?SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk t`+' ♦ WELD COUNTY BOARD OF SOCIAL SERVICES, a �1 ON BEHALF OF THE ' 1 042 �' WELD COUNTY DEPARTMENT OF . 4/� HUMAN SERVICES By �%%//,L !�� . 1 By: Dep ,! lerk to the Board air Signature AUG 2 9 2012 Fiotem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Arapahoe House OF HUMAN SERVICES 8801 Lipan St Thornton, CO 80260 / By: By: ►,y� v retA , �n 4sc( n 's) Director'signees) S hiure a Date and Date 11 x,7O47 asA SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A 4i J013/ ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) /. ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) O/ ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 424.day of-Z between the Weld County Department of Social/Human Services hereinafte called"County" and Attention Homes,3080 Broadway, Suite C, Boulder, CO 80304, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Attention Homes. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called"State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. I 0,240/ '&84;1; SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given,this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: I. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing.No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are$100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to a WELD COUNTY BOARD OF SOCIAL SERVICES, -� ON BEHALF OF THE SI WELD COUNTY �j/ cwt DEPARTMENT OF HUMAN SERVICES IT to WV) Deput 'lerk to the Board ChaiP Signature AUG 2 9 2012 'totem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Attention Homes OF HUMAN SERVICES 3080 Broadway, Suite C Boulder, CO 80304 By: By: �� 727/z_ c ty D. e tor's (o `iesigne, s) eirec .r's (or designee's) Signature S gn+ture a' 4 Date a late 11 c,d/. -aSL SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this I a day of Jy �yy 2O/L between the Weld County Department of Social/Human Services hereinaf{e'r called "County" and C & M Group Home, 1920 81st Ave, Greeley, CO 80634, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with C & M Group Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. SS-23A Revised 2/12 0/a, c231 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 • addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 • 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the aoF+?• WELD COUNTY BOARD s fiat OF SOCIAL SERVICES, ON BEHALF OF THE � WELD COUNTY 61 DEPARTMENT OF HUMAN SERVICES w'.WIC ��By. i , �� 2 L By: Deputy " lerk to the Board Chair Signature 2 9 PROMAUG 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT C & Groin Home OF HUMAN SERVICES 1 0 81st Av reeley, CO 0634 By: By: rr � 7 a2). Co nt Dire t is (or ignee ) irector s (or des' a 's) Signature // Si nat re an ate and Date 11 SS-23A Revised 2/12 q20/c>2' 073)(7 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this E day of ,4 .j )0/2„between the Weld County Department of Social/Human Services herein fter called "County" and Cathedral Home for Children, PO Box 520, Laramie, WY 82073-0520, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Cathedral Home for Children. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agenc esidenti;al ' Care Facility, certified Psychiatric Residential Treatment Facility, o e@ts't�re c - requirements for other licensed service types. SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2112 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: I. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, 4 Sa ON BEHALF OF THE WELD COUNTY asi O q�=; DEPARTMENT OF HUMAN SERVICES Deput r er to the Board Chair Signature AUG 2 9 2012 'totem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Cathedral Home for Children OF HUMAN SERVICES PO Box 520 Laramie, Y 82073-0 20 By: / By; '//j, u ty Dire tor's (or sign s) D' ector's (or designee's) S' ature 'gn ture a Date and Date I I 02047 a2/o`{ SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A _nf) Z CHILD PLACEMENT AGENCY SERVICES (CPA) Z CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this all day of / iaot between the Weld County Department of Social/Hum Services herei fter called "County" and Commonworks D.B.A. Synthesis, 5310 Ward Road, Suite G-01, Arvada, CO 80002, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Commonworks D.B.A. Synthesis. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. O„2©/ - g/cg SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing(if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2)weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing.No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source,the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable,the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws,rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to th- WELD COUNTY BOARD IISL OFSOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY 6s1/42 361 ' m: DEPARTMENT OF HUMAN SERVICES ft By: i/:/, , By:►_. , • ..r. ( 2 /./L. Deputy 'lerk to the Board Chair Signature Protem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Commonworks D.B.A. Synthesis OF HUMAN SERVICES 5310 Ward Road, Suite G-01 Arvada,n CO 80�002Q By: /t 1. ... �� BY: lnY , &OQ.C.. *Sill Coin y Dire ir's (or d�•ignee'sl Director's (or designee's) Signature S'gn. ure an& 1 ate and Date 11 Q70/a7 -o73/a SS-23A Revised 2/12 , AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this day of 41J,,_.,26/e_ between the Weld County Department of Social/Human Services hereinafter called"County" and Cornell Corrections of Texas,Inc., DBA Hector Garza Center, 620 East Afton Oaks Blvd, San Antonio, TX 78232,hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Cornell Corrections of Texas, Inc., DBA Hector Garza Center. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, 1 9O/ -& ig SS-23A Revised 2/12 WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is 2 SS-23A Revised 2/12 completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. 3 SS-23A Revised 2/12 SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. 4 SS-23A Revised 2/12 f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 5 SS-23A Revised 2/12 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be 6 SS-23A Revised 2/12 made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 7 SS-23A Revised 2/12 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer--independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that it; after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 8 SS-23A Revised 2/12 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a 9 SS-23A Revised 2/12 month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable,the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. 10 SS-23A Revised 2/12 (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to they . WELD COUNTY BOARD IS La OF SOCIAL SERVICES, ON BEHALF OF THE '1 WELD COUNTY 1$6i i[f,"C? � DEPARTMENT OF HUMAN SERVICES By: 1% /_ !��_� .��%I� ... By 1, Deput erk to the Board Chair Signature Pattern AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Cornell Corrections of Texas, Inc., OF HUMAN SERVICES DBA Hector Garza Center 620 East Afton Oaks Blvd San A onio, TX 78232 1 1 By: By: 61 ;43. ty Dir or's (or signee' Dire or's (or designee's) Signature ig ture a Date and Date Srn�I��G�1 ?.SAUASbloc, 11 aoia - 073/4 SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this j day of o between the Weld County Department of Social/Human Services herein fter called"County" and Denver Children's Home, 1501 Albion Street, Denver, CO 80220, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Denver Children's Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 C/&- 0%34 SS-23A Revised 2/12 O� NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: I. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: I. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: I. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent,provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are$100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than$100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner,the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, y La ON BEHALF OF THE WELD COUNTY C --, DEPARTMENT OF HUMAN SERVICES 47 try By: Deputy erk to the Board C air Signature harem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Denver Children's Home OF HUMAN SERVICES 1501 Albion Street Denver, CO 80220 By: By: C POP ty 'r ctor's ( design 's) Director's (or designee's) Signature ig ature d Date and Date 11 SS-23A Revised 2/12 a0/07-02-3/rR • AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A DU JUL In A 3S El CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ® RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION El TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this 17 day of J between the Weld County Department of Social/Human Services hereinafter called"County" and Devereux Cleo Wallace, 8405 Church Ranch Blvd, Westminster, CO 80021, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Devereux Cleo Wallace. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 o?i /� (2301 SS-23A Revised 2/12 ' NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement,July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/17 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: I. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 • due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (I), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the s,: WELD COUNTY BOARD ♦ � E La OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY 1661 O DEPARTMENT OF HUMAN SERVICES ) By /�%/� �►��. l�I/I By: Deputy q erk to the Board Cha' ignature fiotem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Devereux Cleo Wallace OF HUMAN SERVICES 8405 Church Ranch Blvd Westminster, CO 80021 By. By C u ty Die fors ( i desig e's) Die or's (or designee S��r�L r e Sin ture Date and Date 11 7 SS-23A Revised 2/12 cx©/427_eWal • AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ S• HELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ O• THER(DESCRIBE): THIS IS AN AGREEMENT, made this j 7 day of Ojai 2°'z between the Weld County Department of Social/Human Services hereinafter called"County" and El Pueblo Boys' and Girls' Ranch, One El Pueblo Ranch Way, Pueblo, CO 81006, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with El Pueblo Boys' and Girls' Ranch. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. SS-23A Revised 2/12 REL:EIvEL; III, 1 ,� 71112 0,7O/al- a. NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2112 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan / Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only,the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent,provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including,the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs)within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 •r contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to th• :4A WELD COUNTY BOARD ,#4 - 114) OF SOCIAL SERVICES, ON BEHALF OF THE 61 t O -1/4 WELD COUNTY DEPARTMENT OF HUMAN SERVICES ft ft By %/L/ I!•►�� % By: O1 -1.7.3 Deputy '" erk to the Board Chair ignature Pram AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT El Pueblo Boys' and OF HUMAN SERVICES Girls' Ranch One El Pueblo Ranch Way Pueblo, CO 81006 By: By: 7/0,t ty Dire tor's (or signee s lector's (or designee's) Signature ig ture Date and Date 11 a? -- a SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this 3/ day of between the Weld County Department of Social/Human Services hereinafter c lled "County" and Evergreen Group Center, 1436 Hilltop Dr., Longmont, CO 80501, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Evergreen Group Center. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 a9/02-asio? NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION 1: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only,the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs)within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable,the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to �` WELD COUNTY BOARD �CJI OF SOCIAL SERVICES, ON BEHALF OF THE 61 t4 � WELD COUNTY DEPARTMENT OF * / HUMAN SERVICES Op By /f%f/) By:b(11 Deputy erk to the Board Chat ignature proton, AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Evergreen Group Center OF HUMAN SERVICES 1436 Hilltop Dr. Longmont, CO 80501 By: By: � Co n y Dir ctQ%gnee' Director's (o desi t e s) Sign. ur= , Sin ure an ate and Date 11 SS-23A Revised 2/12 0219/01 &X 3/2 • AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE El INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) RESIDENTIAL CHILD CARE FACILITY (RCCF) El RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this I day of f e1 .2 b/z- between the Weld County Department of Social/Human Services hereinafter called "County" and Excelsior Youth Centers, 15001 E. Oxford Ave,Aurora, CO 80014, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Excelsior Youth Centers. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. SS-23A Revised 2/12 1 �fl/O7 � NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year,June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, 4 E.,11•8,e) ON BEHALF OF THE s e WELD COUNTY DEPARTMENT OF 1161 HUMAN SERVICES By:/allt . Deput erk to the Board Chair Signature AUG 2 9 2012 Pattern Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Excelsior Youth Centers OF HUMAN SERVICES 15001 E. Oxford Ave Aurora, CO 80014 By: By: 7/is/it Signature ty Di d or's� (or lesign 's) D. ector's (or designee's) Signature ig ature akd Date and Date VarYle> (.��7ei✓I 1L 7),./., oft Zusme-ss ens,*0044 494Pan, 11 �c ' a3/01 SS-23A Revised 2/12 /� , AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of ,261A between the Weld County Department of Social/Human Services herei after called "County" and Families First Children's Treatment Center, 2163 South Yosemite St, Denver, CO 80231, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Families First Children's Treatment Center. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 02-o/07 -07S/0. SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements,the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, Ellsa ON BEHALF OF THE WELD COUNTY DEPARTMENT OF lase HUMAN SERVICES By: 11 ` Deputy erk to the Board hair "otem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Families First Children's OF HUMAN SERVICES Treatment Center 2163 South Yosemite St Denver, CO 80231 By: By: o my Di or's (or signee iD rector's or designee's) Signature ig ature alvd'Date and Date 11 SS-23A Revised 2/12 aO%?-O?2/4 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE El SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this (20 day of 4"p.V/e between the Weld County Department of Social/Human Services herei4.1.04" fter called"County" and Frontier Family Services, 1290 Boston Ave, Longmont, CO 80501-5810, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Frontier Family Services. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 O,7 079- ,9A.-3 SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems,physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. £ Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time,to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than$100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD , S IL, ONOF BEHALFSOCIAL OFSERVICES THE WELD COUNTY ' ctkisier , DEPARTMENT OF 361HUMAN SERVICES ] �� I5Ii �► %y: �l � it By: Deputy ' erk to the Board C r Signature PO- tom AUG 292012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Frontier Family Services OF HUMAN SERVICES 1290 Boston Ave Longmont, CO 80501-5810 By: )2y—�oe� /?/ C u ty Dir c or's (or d signee Director's (or. esiA es)-Signature S n ure d Date and Date 11 ,90/ol —as3 Ay— SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES$"' -`.' r9 SS23A ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this ,A day of 0.20/ z between the Weld County Department of Social/Human Services hereAT), after called"County" and Hope & Home, 4945 N 30th Street, Suite 300, Colorado Springs, CO 80919-3152, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Hope & Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called"State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 670/o7 a �a NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12. addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child,the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 . contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY 4Slide)P DEPARTMENT OF 10 „'&' HUMAN SERVICES /1. •'"` ., Jj . h_____, Deputy t'�rk to the Board Chair Signature PJgtoh. AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Hope & Home OF HUMAN SERVICES 4945 N 30th Street, Suite 300 II/��II Colorado S ing , O 80919-3152 By: J By: i la' C u ty Direic or's (or ignee' Dir c o design e's) Signature S n ture an Date and Date 11 a0/a- a3 L SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES E j8,l JO( �/ pi ® CHILD PLACEMENT AGENCY SERVICES (CPA) ® CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) El RESIDENTIAL CHILD CARE FACILITY (RCCF) El RESIDENTIAL DRUG/ALCOHOL PROGRAM El SHELTER CARE El SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) El OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of go/Z.-between the Weld County Department of Social/Human Services hereinafter called"County" and Imagine, 1400 Dixon Ave, Lafayette, CO 80026, hereinafter called"Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Imagine. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 o/a- &8)c SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement,July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2112 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer independent contractor.No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on"runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to t WELD COUNTY BOARD N r/��p OF SOCIAL SERVICES, 8.f r e ON BEHALF OF THE ,,- ..,a WELD COUNTY 1861 ' •.' } �' DEPARTMENT OF V,:.1 HUMAN SERVICES y By: By: 9 Deputy erk to the Board Chair Ignature Proem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Imagine OF HUMAN SERVICES 1400 Dixon Ave Lafayette, CO 80026 By: By: '46-- Co nt Dire to 's (or d gnee's Di ect r designee's) Signature Si na re an ate and Date 11 SS-23A Revised 2/12 cQQ/q7- c SM AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this A 3 day of ,'p/ ? between the Weld County Department of Social/Human Services hereina er called"County" and Jefferson Hills, 421 Zang St, Lakewood, CO 80228, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Jefferson Hills. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 aeVoi—aSiol SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source,the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, (� ON BEHALF OF THE WELD COUNTY DEPARTMENT OF Ito 1/4r) i:: HUMAN SERVICES A By. G L/ Deput lerk to the Board Chair SignatureAUG 2 9 2012 !totem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Jefferson Hills OF HUMAN SERVICES 421 Zang St Lakewood, CO 80228 By: �I I II1 � By: Arta C ty Dire tor's o esigne s r tor's (or desi ee's) Sigh, ure g .ture i . Date and Date 11 SS-23A Revised 2/12 ao/a -a-4/ci AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A 7012 JUL 1 (I A q: 35 ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this /2 day of 2o/Z between the Weld County Department of Social/Human Services hereina er called"County" and Kids Crossing, 1440 E Fountain Blvd, Colorado Springs, CO 80033, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Kids Crossing. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 O,2 04.? a-giP SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing(if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only,the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY J *� DEPARTMENT OF HUMAN SERVICES By: Deputy 'lerk to the Board Cha�gnatureAUG 2 9 2012 Piotsm Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Kids Crossing OF HUMAN SERVICES 1440 E Fountain Blvd Colorado Springs, CO 80033 By: By: -7 / �Z- o ty it ctor's ( desig 's) Directo s (or designee's) Signature Sig atur d Date and Date 11 SS-23A Revised 2/12 020/0 c3/ • AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 1 7 day of V 20/2 between the Weld County Department of Social/Human Services hereinafter called"County" and Kids Resource Network of Colorado Springs, 6285 Leham Dr., Suite 101, Colorado Springs, CO 80918, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Kids Resource Network of Colorado Springs. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS,the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 &O/ R 073/4 SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: I. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining finds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time,to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than$100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (I), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to WELD COUNTY BOARD t . SLa . OF SOCIAL SERVICES, ON BEHALF OF THE '� WELD COUNTY \I6 DEPARTMENT OF HUMAN SERVICES By: %�-..�/�/,L 1di �/% By: —� Deputyrerk to the Board hair Signature Protem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Kids Resource Network OF HUMAN SERVICES of Colorado Springs 6285 Leham Dr., Suite 101 Colorado Springs, CO 80918 By: e . I II I. BYAgl 11I l 1 a my Ii ector's o desi_u e's) ector's (or designee's) Signature Si,natu • . d Date and Date 11 n7O4?- 07g/if SS-23A Revised 2/12 . AGREEMENT TO PURCHASE /4 OUT-OF-HOME PLACEMENT SERVICES '4 SS23A /0 ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE(RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this /qi' day of—)al y 1D i Z between the Weld County Department of Social/Human Services hereinafter called"County" and Lutheran Family Services Rocky Mountains, , , hereinafter called"Contractor." 36.3 S• l-{cfr l Qn 5te-ZO O , Din KA^ eo% )Z-z6 THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Lutheran Family Services Rocky Mountains. A child specific addendum,identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement,the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS,the Colorado State Department of Human Services,hereinafter called"State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules,and WHEREAS,the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency,Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30)days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty(30)days or until the eligible child(ren)can be placed elsewhere, whichever occurs first,and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements,the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and,for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F(12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However,provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies,which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7)days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure,where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL,TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract.The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior,support system in the community,available resources,and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency,and duration of clinical therapy services, rehabilitation services,medication management, emergency services, initial assessment, documented treatment modifications,and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning,changes in the child's family situation,educational progress, significant incidents or disciplinary actions,and progress made to achieve goals specified in the treatment plan. Further,the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition,psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing(if appropriate), the State of Colorado and any applicable federal laws and regulations, as such,which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3.Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973,Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and$400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2)months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts,omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy&Financing,and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death,to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance,or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents,or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal,Colorado Department of Human Services, Colorado Department of Health Care Policy &Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent,provide the initial home study,the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate,CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance,and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor.No agent,employee, or servant of Contractor shall be deemed to be an employee, agent,or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever,unless embodied herein in writing. No subsequent notation, renewal, addition, deletion,or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to,but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on"runaway"status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source,the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1)The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject,at any reasonable time,to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2)All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month,for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3)All Contractors whose total annual expenditures are$100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than$100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements,prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133,Audits of States,Local Governments, and Non- Profit Organizations including subsequent revisions,and appropriate audit and financial reporting requirements as defined in State laws, rules,and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions,penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County,as a debt due to both the State of Colorado,the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD ada� OF SOCIAL SERVICES, SIN BEHALF OF THE �t ELD COUNTY 1O1 EPARTMENT OF '•��' �;UMAN SERVICES By: `a /��I `i� / ��,_ L A ,�_ ��':►� �' �� Deputy irk to the Board Chair ignature AUG 2 9 2012 ?mtem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Lutheran Family Services OF HUMAN SERVICES Rocky Mountains 2032 Lowe Street, Suitc 200 3 S. 1-1-41r164454 �,� e2 45 F Oen, ey', Cell of L( By: /,i . 1.1 �• '.1.: By:c ty Dir tor's o esigne- ) Director's (or designee's) Signature el , •ig atur&an. Date and Date find/j, -4•1!-I NU-1-1 P 11 SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A 1611 JUl 30 P t2' 12 ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this 3 day oflr_between the Weld County Department of Social/Human Services herei after called"County" and Maple Star Colorado,2785 Speer Blvd, Suite 340, Denver, CO 80211, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Maple Star Colorado. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 arA9 - a�ic SS-23A Revised 242 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems,physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only,the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent,provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE La\ WELD COUNTY ', DEPARTMENT OF 1861 s � HUMAN SERVICES By:4/1/Ad_ C:zt Deputy Perk to the Boar. "" Chair Signature ?formAUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Maple Star Colorado OF HUMAN SERVICES 2785 Speer Blvd, Suite 340 Denver, � 1CO ✓il Q 80211 By: By: I ��x a1 l r/"A5-Ol C y Dire or's (or signe ) irector's (qr d signee's) Signature S n ture a Date and Date 11 SS-23A Revised 2/12 °W.)?- ,9/o AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this I to day of tJu14 , O/ between the Weld County Department of Social/Human Services hereindfter called "County" and Marie Alirez Group Home, 1405 26th Street, Greeley, CO 80631, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Marie Alirez Group Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 c;)0/02 - SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/U addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. I Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing(if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 • 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, 15 E,La ON BEHALF OF THE WELD COUNTY DEPARTMENT OF 18fi1- O HUMAN SERVICES By: Deput < ler to the Board """ hal ignature Protean AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Marie Alirez Group Home OF HUMAN SERVICES 1405 26th Street Greeley, CO 80631 By: ' ' .I i' 7-16- o ty I i ector' j or des y. ee's) Director's (or designee's) Sig iature S'_natu < . d Da = and Date 11 t7,0A2- a$/o1 SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this IF? day of O.c ,27(.),27(.)/2,, between the Weld County Department of Social/Human Services herein r called"County" and Michael Alirez Group Home, 1709 37th Ave, Greeley, CO 80634, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Michael Alirez Group Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 oW,0 - a�f? SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: I. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/17 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Cl •� ' �er r .(;It � ;J% WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES By: � � ��Li `— . ✓ By: Deputy 'erk to the Board Chair ignature AUG 2 9 2012 fotem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Michael Alirez Group Home OF HUMAN SERVICES 1709 37th Ave Greeley, CO 80634 By: A h ♦ �1-.�.I/� By: /2 _ /2- o ty Pir ctor's desig :e's) Director's (or e gnee 'gnature •• ature . d Date, and Date 11 ,20/O7— �/c SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) • RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of ic,frgzoi 2o,z- between the Weld County Department of Social/Human Services hereinafter called"County" and Mountain Crest Poudre Valley Health Care Inc. D/B/A Poudre Valley Hospital, 4601 Corbett DR, Fort Collins, CO, 80528, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Mountain Crest Poudre Valley Health Care Inc. D/B/A Poudre Valley Hospital. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, 1 SS-23A Revised 2/I7 (9©/-02314 WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is 2 SS-23A Revised 2/12 completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. 3 SS-23A Revised 2/12 • SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. 4 SS-23A Revised 2/12 f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 5 SS-23A Revised 2/12 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be 6 SS-23A Revised 2/12 made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 7 SS-23A Revised 2/12 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 8 SS-23A Revised 2/12 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. A. All reimbursement requests shall be submitted to and approved by the appropriate County staff Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a 9 SS-23A Revised 2/12 month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are$100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. 10 SS-23A Revised 2/12 (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD �r ♦ OF SOCIAL SERVICES, . �V4�° a ON BEHALF OF THE WELD COUNTY ' �� DEPARTMENT OF �� `': HUMAN SERVICES By: H I1 ti��r i , Deput Jerk to the Board Chair SignatureAUG 2 9 202 protein Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Mountain Crest Poudre Valley OF HUMAN SERVICES Health Care Inc. D/B/A Poudre Valley Hospital 4601 Corbett DR Fort Collins, CO, 80528 By: By: lQ�r> C 0 0 1, 2-3-11- o my D r tor's (o esignee ) Director's (or designee's) Signature ig ature Date and Date LSS-23A Revised 2/12 11 d7c/a- (2 3/61 roil AGREEMENT TO PURCHASE ,fib OUT-OF-HOME PLACEMENT SERVICES v`P6 SS23A .4 51 3 ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this , .3 day of I a 012, between the Weld County Department of Social/Human Services herei fter called"County" and New Start Youth Services LLC, PO Box 1932, Pueblo, CO 81002, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with New Start Youth Services LLC. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 0/07 - `Q3A NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, fON BEHALF OF THE WELD COUNTY ;� DEPARTMENT OF 4in' �"� HUMAN SERVICES By Deputy r erk to the Board Chairnature Proton-, AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEW START YOUTH SERVICES P 0 BOX 1392 PUEBLO, COLORADO 81002 By: By: ratf Ldfti!71/41 C ty D're tor's (o esigne Director's (or designee's) Signature S gn ture Date and Date 11 ep _ 0731a2 SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ® CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING LI PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of/tp41I'p/e between the Weld County Department of Social/Human Services hereinafter called"County" and Parker Personal Care Homes Inc., 5394 Marshall Street, Arvada, CO 80002, hereinafter called"Contractor" THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Parker Personal Care Homes Inc.. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement AgencypResidentialfhilgi Care Facility, certified Psychiatric Residential Treatment Facility, or Yrieds the requirements for other licensed service types. 620/01 c?S/0 SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION 1: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least$25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (I) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD ♦�+�� OF SOCIAL SERVICES, y .�� \L t s ON BEHALF OF THE • WELD COUNTY •N"� �, DEPARTMENT OF 1161 _�I.r %,��l.• �, HUMAN SERVICES : 1/6 Deputy clerk to the Board Chair Sig ur�G 2 9 2012 proem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Parker Personal Care Homes Inc. OF HUMAN SERVICES 5394 Marshall Street Arvada, CO 80002 By: tsL , l . .`S By: �1 2-S11/2-- ty Direc ,r's (or .ignee'st 2,Ann rector' o desi s) Signature `ig :ture . s late and Date I 1 aO/a a2, SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A B17 JUI. 23 A I() 35 ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ® PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this / day of Alpo)/(-720/e. between the Weld County Department of Social/Human Services hereinafter called"County" and PSI Cedar Springs Hospital,Inc.,2135 Southgate Rd, Colorado Springs, CO 80906- 2605, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with PSI Cedar Springs Hospital,Inc.. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 cat)/c9 -c 8/c NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 242 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ISL'a � ON BEHALF OF THE -, WELD COUNTY 1861 �� DEPARTMENT OF HUMAN SERVICES Deputy erk to the Board l�l Chair 'IgnaturALI 0 2 9 2012 tinter) Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT PSI Cedar Springs Hospital, Inc. OF HUMAN SERVICES 2135 Southgate Rd Colorado Springs, CO 80906-2605 I By: �IL�.�u1� ��i By: JQ/u,( r)-/9 ' o my Pir ctor s (. .esigne ) Director's (or designee's) Signature i: ature :. d Date and Date 11 SS-23A Revised 2/12 C)? 023/4 • AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ® CHILD PLACEMENT AGENCY SERVICES (CPA) ® CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this i 7 day of EL) do,z between the Weld County Department of Social/Human Services hereinafter called "County" and Quality Life Services LLC, 11975 Reed Street, Broomfield, CO 80020, hereinafter called"Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Quality Life Services LLC. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 0,212/o7 (2,91c2SS-23A Revised 2/12 - NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan / Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 • addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 • h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 • 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child,the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA,then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 • contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, y 4Elloa ON BEHALF OF THE WELD COUNTY DEPARTMENT OF est 44 HUMAN SERVICES • By: Deputy Perk to the Board C ' ignature AUG 2 9 2012 plotem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Quality Life Services LLC OF HUMAN SERVICES 11975 Reed Street Broomfield, CO 80020 By: JI t l./ I 1 2 �il�. ..//. By: 1,144l, 7/7/04 C.f�'ty Di e:tor's (or i�•signee' Director's (o designee's) Signature g :ture . • Date and Date [[[ 11 20/c? ` � f SS-23A Revised 2/12 c8/o AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ® RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this I day of /:4i / r between the Weld County Department of Social/Human Services hereinafter called"County" and Reflections For Youth, Inc., PO Box 1860, Berthoud CO 80513, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Reflections For Youth, Inc. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. SS-23A Revised 2/12 1 O2Q/a— 0X-420 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 242 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD • �� OF SOCIAL SERVICES, /� F �� S La ON BEHALF OF THE .Y / , WELD COUNTY DEPARTMENT OF 1461 �•� HU N SERVICES By /I 1.i L i ��_ . %I1R=�r'► • Deputy Crk to the Board Chair ignature AUG 2 9 2012 Piotem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Reflections For Youth, Inc. OF HUMAN SERVICES PO Box 1860 Berthoud CO 80513 By: By: jt,81`-4(, •12), It C n y Dir c is (or signee ) Direct r s r designee's) Signature Si ure a ate and Date 11 SS-23A Revised 2/12 7��- /(� AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ® CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this .3 day of Azycidlis1oiL between the Weld County Department of Social/Human Services hereinafter called"County" and Rocky Mountain Kids, 2210 E. LaSalle Street, #219, Colorado Springs, CO 80909, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Rocky Mountain Kids. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. l /�—( 7c3i SS-23A Revised 2/12 �� NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor.No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado,the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD p0" ♦ OF SOCIAL SERVICES, /� #rN I ' ( 4�)%� ON BEHALF OF THE y is 4AWELD COUNTY i r DEPARTMENT OF 1a �%ij+ 6'e 81 � HUMAN SERVICES By: � V !/f -- 10�!!%i t :�n.r'�;y; Deput rlerk to the Board Chair ignature fp/otem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Rocky Mountain Kids OF HUMAN SERVICES 2210 E. LaSalle Street, #219 Colorado Springs, CO 80909 By: LC 161 By: .7)X3117 C u ty Die tor's (o esigne s) Director's (or desi ee s) Signature ature kn Date and Date 11 SS-23A Revised 2/12 a19/a - aS/c5i AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A q 39 1111 ,1L11 q A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ® CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) Z RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this I? day of J uiii between the Weld County Department of Social/Human Services hereinafter called"County" and Roundup Fellowship,2250 S Oneida, Suite 201, Denver, CO, 80224, hereinafter called"Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Roundup Fellowship. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 O7©/o2 — (RSA; SS-23A Revised 242 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven(7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2R2 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 . contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the •- WELD COUNTY BOARD '1n to � OF SOCIAL SERVICES, 4 ON BEHALF OF THE a WELD COUNTY -Y ,T%61 r'O.L�lel DEPARTMENT OF I� � "IV HUMAN SERVICES / %®U 'C' � By: I r PIA i U. .�.L-. "`..I, . _, Deput lerk to the Board Chai ' nature prom AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Roundup Fellowship OF HUMAN SERVICES 2250 S Oneida, Suite 201 Denver, CO, 80224 By: By: / � � 1 �/'k o rty r tor's (ci design s) irecto (or designee's) Signature ig ature Date and Date 'vim 11 SS-23A Revised 2/12 o7D�t2-&SIC AGREEMENT TO PURCHASE 4,"/.i OUT-OF-HOME PLACEMENT SERVICES r!� SS23A r <19 ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this 2 day of vie_ between the Weld County Department of Social/Human Services herei fter called"County" and Savio House,325 King St, Denver, CO 80219, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Savio House. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. l ar/a- a a/a SS-23A Revised 2/12 • NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death,to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD Ado �� OF SOCIAL SERVICES, a ON BEHALF OF THE wt►% a WELD COUNTY C, e - DEPARTMENT OF �'4tart "1"01 HUMAN SERVICES By: ,i.�ii�i "W1%7 , ,)t & 42 Deputy ' erk to the Board ir Si atuce rioter) AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Savio House OF HUMAN SERVICES 325 King St �� Denver, CO 80219 �%l//By: By: l 9 3 u ty Die tor's (oi esignee Director's (or designee's) Signature ig ature Date and Date 11 &0/a — a3/4 SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ,,,, 2 3 A 10: 33 ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this / day of 7- ,,fois.between the Weld County Department of Social/Human Services herein fter called"County" and Shiloh Home, 6400 W Coal Mine Ave, Littleton CO 80123, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Shiloh Home. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called"State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 O©/a- 07''9j" NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing(if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent,provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHAP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source,the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time,to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-I33, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the B.. . WELD COUNTY BOARD Es L OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY 1u1 �s442 DEPARTMENT OF �4% I HUMAN SERVICES / � rr By: ///�Q,�i 1�1 / / :y. Deputy erk to the Board Chair Signature item, AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Shiloh Home OF HUMAN SERVICES 6400 W Coal Mine Ave Littleton CO 80123 By: By) awv, E'. 07/13/2012 my Di ector's r desi e's) irector's (or desig x) Signature ,Si natur d Date and Date Steven Ramirez/CEO 11 SS-23A Revised 2/12 ,20/O2- O73/O? AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ® CHILD PLACEMENT AGENCY SERVICES (CPA) ® CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ® GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ® RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this n day of 7U!} / a.o O /a-between the Weld County Department of Social/Human Services hereinafter called"County" and Smith Agency, 14394 E. Evans Ave, Aurora, CO 80014, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Smith Agency. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 242 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child,the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on"runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than$100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD �� S OF SOCIAL SERVICES, •/�, • 1. " �� N. ON BEHALF OF THE WELD COUNTY tar11.1 DEPARTMENT OF � •% .. HUMAN SERVICES - 1 / i 00,/ ( 1 \ ♦ By: / i.st4! //_ arro Z % Af a Deputy 'erk to the Board Chair ..t. ature Plotem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Smith Agency OF HUMAN SERVICES 14394 E. Evans Ave Aurora, CO 80014 By: By: di, Ij / n y Direc or's (or signee Director's (or designee's) Signat re Sin urea d Date and Date 11 - O7S/o; SS-23A Revised 2/12 p7�� 1 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) Z CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of TiZ0O between the Weld County Department of Social/Human Services hereina er called"County" and Special Kids Special Families, 424 W Pikes Peak Ave, Colorado Springs, CO 80905, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Special Kids Special Families. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 �©/a- asiq SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 '4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing(if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 '7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12. '13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 'contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk t.`utaty..„` WELD COUNTY BOARD #��4 1(,®N OF SOCIAL SERVICES, v iy � ON BEHALF OF THE C " IR ��.vn = I WELD COUNTY is 4• ; DEPARTMENT OF ray' 1, HUMAN SERVICES e"? BY //�i A 9atff1 By: Deputy 'lerk to the Board Chair Signature Piotem AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Special Kids Special Families OF HUMAN SERVICES 424 W Pikes Peak Ave Colorado Springs, CO 80905 77/6 f l By: By: l /��1� t Di designee's) c y e tors (o design s) ect r s ( r gnature 'g ature Date and D to 11 a,20/4-a3/q SS-23A Revised 242 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ® RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER(DESCRIBE): THIS IS AN AGREEMENT, made this day of o/2 between the Weld County Department of Social/Human Services herei fter called "County" and Tennyson Center for Children, 2950 Tennyson St, Denver, CO 80212-3029, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Tennyson Center for Children. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 g2O/p7 �3/pi NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement,July 1, 2012, until the end of the Colorado fiscal year, June 30, 2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren)to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor.No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are$100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Bo ryo 'w s% WELD COUNTY BOARD s La., OF SOCIAL SERVICES, ef a ON BEHALF OF THE y: WELD COUNTY vial t:,�0 DEPARTMENT OF 104;661,9�$ HU SERVICES Deputy ' erk to the Board Chair SignatureAUG 2 9 Z01? totem Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Tennyson Center for Children OF HUMAN SERVICES 2950 Tennyson St Denver, CO 80212-3029 By: V By: �Gli+v � '2ejr2 ntY D e toy's ( desig e's) Director's (or designee's) Signature ig ature Date and Date 11 0.2t9/v- ,Q3/o SS-23A Revised 2/12 • AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): THIS IS AN AGREEMENT, made this 3 day of 6/z between the Weld County Department of Social/Human Services herein er called"County" and Third Way Center, PO Box 61385, Denver, CO 80206, hereinafter called "Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Third Way Center. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called"State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of SociaUHuman Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. 1 SS-23A Revised 2/12 q?i 31c,2 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/ Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. f. Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (I) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner,the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA,then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, f"La�� ON BEHALF OF THE ,p #% WELD COUNTY ISM DEPARTMENT OF �.,;.� HUMAN SERVICES • By: Deputy Perk to the Board Chair nature Pattern AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Third Way Center OF HUMAN SERVICES PO Box 61385 De r, CO 80206 By �. . ��. . .� �r. By: ty Di e tor's (o •esigne s) Director's (or designee's) Signature ig r ature ..,a Date and Date 11 owe?„693 f� SS-23A Revised 2/12 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES (CPA) ❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY (RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) ❑ OTHER (DESCRIBE): , -a THIS IS AN AGREEMENT, made this / day of`��o?o/r between the 9 Weld County Department of Social/Human Services herei aftef called"County" and i,� Whimspire CPA, 4575 Galley Rd, Suite 400A, Colorado Springs, CO 80915-2750, — hereinafter called"Contractor." THIS AGREEMENT: Shall include all children placed by the Weld County Department of Social/Human Services and placed with Whimspire CPA. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the facility. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter called "State Department" is authorized to provide social services to individuals and families of individuals through its agents, County Departments of Social/Human Services, and WHEREAS, the County is authorized to purchase certain services for eligible children under State Department rules, and WHEREAS, the County wishes to provide these services by purchasing them from Contractor, and, WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. I ,90/G- c23/cN. SS-23A Revised 2/12 NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and the Contractor agree as follows: 1. This Agreement shall be in force from the date of the agreement, July 1, 2012, until the end of the Colorado fiscal year, June 30,2013. Any child may be removed from the facility prior to the end of the fiscal year by the county department. 2. This Agreement may be renewed only by entering into a new written Agreement such as this Agreement signed by the authorized representatives of the parties. Except as otherwise provided above, either party shall have the right to terminate this contract by giving the other party thirty (30) days notice by registered mail, return receipt requested. If notice is so given, this contract shall terminate on the expiration of the thirty (30) days or until the eligible child(ren) can be placed elsewhere, whichever occurs first, and the liability of the parties hereunder for further performance of the terms of this Agreement shall thereupon cease, but the parties shall not be released from the duty to perform their obligations up to the date of termination. 3. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. SECTION I: DESCRIPTION OF SERVICES TO BE PURCHASED: 1. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and the Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. 2. Payment for a child's temporary absence from the facility, including absence due to hospitalization, will be made in accordance with State Department rules in Staff Manual Volume VII, 7.406.1, F (12 CCR 2509-5). 3. Transportation shall be furnished by County between the child's residence and Contractor's facility for the initial placement and return after the treatment plan is completed. If the child runs away from the Contractor's facility, the County shall provide transportation to either return the child to the facility or to other care as arranged by the County. The County has responsibility for the decision to return the child to the facility, with input from the Contractor. 2 SS-23A Revised 2/12 4. All other transportation associated with the Contractor's proposed services will be provided by Contractor. Any transportation costs not covered or contemplated in the original treatment plan must be negotiated between County and Contractor and are not subject to reimbursement under this Agreement. However, provisions for payment of other transportation may be provided for in the Family Service Plan/Individual Plan of Care. 5. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this contract, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. SECTION II: LEGAL STATUS AND AUTHORIZATIONS: 1. Such permission as is held by the County is hereby granted to the Contractor to authorize routine or emergency medical and dental treatment except that: a. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. 2. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. 3. It is agreed and permission is granted for the child(ren) to participate in planned recreational and social activities of Contractor, including supervised off grounds excursions and extended trips within the State, provided that Contractor has written permission from County and legal guardian for any trips out of Colorado for any reason and any planned absence from the facility of over seven (7) days within a consecutive 30- day period. Such written permission may be in the treatment/service plan. Further, Contractor and County will also secure, where possible, permission from parents or guardians of the child placed with the Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. 4. County and Contractor shall inform each other and the local school district of any changes in parental residence affecting educational status which comes to their attention. SECTION III: REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS REPORTS: 1. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children are specified in the attached child specific 3 SS-23A Revised 2/12 addendum and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the addendum. 2. County and Contractor shall develop an initial plan that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes except PRTF. County and Contractor shall formulate an initial individual plan of care within 14 calendar days after admission for children in RCCFs or group homes except PRTF. The placement date is that date noted in the attached child specific addendum included with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 3. County and Contractor shall formulate an initial individual plan of care for children in PRTFs within 72 hours. For children in a PRTF a comprehensive individual plan of care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the attached child specific addendum included with this contract. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. 4. The individual plan of care shall be goal oriented and time-limited and shall: a. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8) together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. c. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. d. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. e. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. £ Anticipated living arrangement for the child at the date of discharge; g. Anticipated educational arrangement for the child at the time of discharge; 4 SS-23A Revised 2/12 h. Anticipated date for discharge from treatment purchased for the child. i. A permanency goal for the child. 5. Monthly, Child Placement Agencies, RCCFs and other contractor types other than PRTF, shall conduct a monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved or not achieved. These parties shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, the Contractor agrees to sequence reports to be received by the County 15 calendar days prior to judicial or administrative hearings or reviews when provided with 30 calendar days advance notice of such dates by County. 6. Every 14 days, PRTFs shall provide the County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. SECTION IV: CONTRACTOR SHALL: 1. Conform with and abide by all rules and regulations of the Colorado Department of Human Services, the Colorado Department of Health Care Policy and Financing (if appropriate), the State of Colorado and any applicable federal laws and regulations, as such, which may be amended from time to time, and shall be binding on Contractor and control any disputes in this Agreement. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to children or families of children referred by county for any services provided under this Agreement. 4. Not assign the obligations under this Agreement nor enter into any sub-contract without the express written approval of the Director of the County Department or his/her appointed designee. 5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act of 1975 as revised, and provide confidentiality of information concerning the child in compliance with the Health Insurance Portability and Accountability Act(HIPAA). 6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs and $400,000 for PRTFs, and RCCFs for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. 5 SS-23A Revised 2/12 • 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2) months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this contract in order to make reparations for any wrongful acts, omissions, or any other defalcations of the Contractor. 8. Indemnify County, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, and the State of Colorado against any and loss against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused or sustained in connection with the performance of this contract or by conditions created thereby, or based upon any violations of any statute, ordinance, or regulation and the defense of any such claims or actions. Paragraphs 6, 7 and 8 do not apply to the University of Colorado contracts with county departments. 9. In regards to University of Colorado contractors only, the contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24- 10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. 10. Maintain service program records, fiscal records, documentation and other records, which will sufficiently and properly reflect all direct and indirect costs of any nature incurred in the performance of this Agreement. The above shall be subject at all reasonable times to inspection, review or audit by federal, Colorado Department of Human Services, Colorado Department of Health Care Policy & Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. Contractor shall, in any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times the Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and the Contractor, during regular business hours. 12. Bill the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for—service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within 30 calendar days following the billing due date. 6 SS-23A Revised 2/12 13. Attend and participate in Administrative Reviews for children in placement with the Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. The Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. SECTION V: COUNTY SHALL: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human Services. 3. Reimburse Contractor by the 15th of the following month in accordance with fiscal system time frames for services purchased under this Agreement in accordance with the established rate when billing is submitted as described in Section IV,Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human Services, federal rules and regulations and the laws of the State of Colorado, any of which may be amended from time to time. 5. If this agreement covers an initial placement for a child, the Contractor may receive a clothing allowance in accordance with State Department rules. 6. Monitor children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 7. Invite Contractor to Administrative Reviews at least 2 weeks prior to the scheduled review. 8. Involve Contractor in planning for the child and give the Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 9. The County shall seek recovery from the RCCF, CPA or other contractor type for any non-Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other contractor type. The County shall seek recovery of any remaining funds as a debt 7 SS-23A Revised 2/12 due the County for the benefit of the state. The RCCF or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 10. The County shall identify the amount agreed upon with the Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. 11. Reimbursement rates that are negotiated between the County and the Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. SECTION VI: GENERAL PROVISIONS: 1. The Parties to this Agreement intend that the relationship between them, contemplated by this Agreement is that of employer—independent contractor. No agent, employee, or servant of Contractor shall be deemed to be an employee, agent, or servant of the County. Contractor will be solely and entirely responsible for its acts or of any agent, employee, servants and sub-contractors during the performance of this Agreement. 2. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds, whether in whole or in part, is subject to and contingent upon the continuing availability of State of Colorado, county, and federal funds for the purpose thereof. 3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and protect personal items brought to Contractor by the children, Contractor will be released from responsibility for loss or damage to such personal items. 4. This Agreement is intended to be applied in conjunction with the child specific addendum and family services plan as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion or other amendment hereto shall have any force or affect whatsoever, unless embodied herein in writing. No subsequent notation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied as a part of this written Agreement. This section shall not be construed as either prohibiting the periodic amending of the family services plan or appending a county designed addendum to this agreement. 5. The contract shall permit the State Department to monitor service program, fiscal and other records sufficiently to assure the purchase of services in this Agreement are carried out for the benefit of the aforementioned client. Monitoring may occur through review of program reports, on-site visits where applicable and other contracts as deemed necessary. The Contractor understands that the State Department may provide consultation to Contractor to assure satisfactory performance in the provision of purchased services under this Agreement. 8 SS-23A Revised 2/12 A. All reimbursement requests shall be submitted to and approved by the appropriate County staff. Reimbursement for placement services shall be paid from the date of admission up to, but not including, the day of discharge. Furthermore, Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this contract and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Reimbursement requests for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The Contractor shall forward copies of such billings to the County on a monthly basis. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, the Contractor shall refund those dollars forthwith. B. The purpose of these requirements is to provide minimum assurance that the Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to the county departments of human/social services and Colorado Department of Human Services for the use of public funds. (1) The Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). The Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of the Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. (2) All billing by the contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. (3) All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed 9 SS-23A Revised 2/12 financial statements, prepared in accordance with generally accepted accounting principles. If the Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services (Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after the contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this contract and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of the Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, the Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. (4) If Contractors do not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner,the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If the contractor is a CPA, then sanctions of the contractor may occur for failure to submit. (5) In cases where documentation does not exist to support audit information or services provided, contractor will be required to repay all funds received for which documentation does not exist. (6) In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within 4 months of the date of the audit. (7) Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose fiscal sanctions, penalties, or cancel the contract. 6. In the event this contract is terminated, final payment to the Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to the Contractor due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor either by deduction from subsequent payments under this contract or other 10 SS-23A Revised 2/12 contracts between the County and the Contractor or by the County, as a debt due to both the State of Colorado, the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this contract or appropriate statutes and regulations. WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. ATTEST: Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, , . s La� ON BEHALF OF THE y �p WELD COUNTY t�"'t DEPARTMENT OF yes .,,�„�r HUMAN SERVICES to By: #1 I �. /�>,•_...,:•+•y. Deputy 'lerk to the Board Chas Signature 1°ioten, AUG 2 9 2012 Approval as to Substance: CONTRACTOR WELD COUNTY DEPARTMENT Whimspire CPA OF HUMAN SERVICES 4575 Galley Rd, Suite 400A Colorado Springs, CO 80915-2750 By: By: l l 19 l Z Co n y Dire t is (or d ignee's D e or's (or designee's) ignature Si n ture an ate a Date 11 ado/a- c7eB/o3 SS-23A Revised 2/12 Hello