HomeMy WebLinkAbout20112197 MEMORANDUM
1 8 6 1 - 2 0 1 1 DATE: August 4, 2011
1
TO: Barbara Kirkmeyer, Chair, Weld County Board Commissi9ryer
T
ELD -CO � TY L �) 4FROM:Judy A.Griego,Director,Human Services De mnt� RE: Agreement to Purchase Out-of-Home Placement 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 presented at the Board's June 20, 2011, Work
Session. Please place on the Consent Agenda.
Below are the major provisions of the attached Agreements:
No. Facility Name/Term Facility Type/Location
1 A.M. Group Home Group Home/Group Center Care
July 1, 2011 —June 30, 2012 Platteville, Colorado
2 Residential Child Care Facility
Alternative Homes For Youth Therapeutic Residential Child Care Facility
July 1, 2011 —June 30,2012 Dacono, Colorado
3 Attention Homes Residential Child Care Facility
July 1, 2011 —June 30,2012 Boulder, Colorado
4 C & M Group Home Group Home/Group Center Care
July 1,2011 —June 30, 2012 Greeley, Colorado
5 Cathedral Home for Children Transition/Home Based After-Care
July 1, 2011 —June 30, 2012 Laramie, Wyoming
6 Denver Children's Home Residential Child Care Facility
July 1, 2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Denver, Colorado
7 Devereux Cleo Wallace Psychiatric Residential Treatment Facility
July 1, 2011 —June 30, 2012 Residential Child Care Facility
Therapeutic Residential Child Care Facility
Westminster, Colorado
8 El Pueblo Boys' and Girls'Ranch Residential Child Care Facility
July 1, 2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Pueblo, Colorado
9 Excelsior Youth Centers Residential Child Care Facility
July 1,2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Aurora, Colorado
10 Families First Children's Treatment Center Residential Child Care Facility
July 1, 2011 —June 30, 2012 Denver, Colorado
II Griffith Center for Children Residential Child Care Facility
July 1, 2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Westminster, Colorado
12 Heritage House Child Placement Agency Services
July 1, 2011 —June 30, 2012 Group Home/Group Center Care
Louisville, Colorado
13 Imagine Child Placement Agency Services 7//f
July 1, 2011 —June 30, 2012 Child Residential Habilitation Program /'
Lafayette, Colorado
Cl"VWIttClQitk -/61-.. (2%7 LQ. )O 2011-2197
14 Jefferson Hills Residential Child Care Facility
July 1, 2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Lakewood, Colorado
15 Kids Crossing Child Placement Agency Services
July 1, 2011 —June 30, 2012 Group Home/Group Center Care
Colorado Springs, Colorado
16 Kids Resource Network of Colorado Springs Child Placement Agency Services
July 1, 2011 —June 30, 2012 Colorado Springs, Colorado
17 Maple Star Colorado Child Placement Agency Services
July 1, 2011 —June 30, 2012 Group Home/Group Center Care
Denver, Colorado
18 Marie Alirez Group Home Group Home/Group Center Care
July 1, 2011 —June 30, 2012 Greeley, Colorado
19 Michael Alirez Group Home Group Home/Group Center Care
July 1, 2011 —June 30, 2012 Greeley, Colorado
20 Mount St. Vincent Home Group Home/Group Center Care
July 1, 2011 —June 30,2012 Residential Child Care Facility
Therapeutic Residential Child Care Facility
Denver, Colorado
21 Mountain Crest Poudre Valley Health Care Inc. Residential Child Care Facility
D/B/A Poudre Valley Hospital Therapeutic Residential Child Care Facility
July 1, 2011 —June 30, 2012 Fort Collins, Colorado
22 Reflections For Youth, Inc. Residential Child Care Facility
July 1, 2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Berthoud, Colorado
23 Regents of the University of Colorado, a body Residential Child Care Facility
corporate, for and on behalf of the UC Denver Therapeutic Residential Child Care Facility
July 1, 2011 —June 30, 2012 Denver, Colorado
24 Roundup Fellowship Child Residential Habilitation Program
July 1, 2011 —June 30, 2012 Residential Child Care Facility
Denver, Colorado
25 Savio House Child Placement Agency Services
July 1, 2011 —June 30, 2012 Group Home/Group Center Care
Residential Child Care Facility
Therapeutic Residential Child Care Facility
Denver, Colorado
26 Special Kids Special Families Child Placement Agency Services
July 1,2011 —June 30, 2012 Child Residential Habilitation Program
Colorado Springs, Colorado
27 Tennyson Center for Children Residential Child Care Facility
July 1, 2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Denver, Colorado
28 Third Way Center Residential Child Care Facility
July 1,2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Denver, Colorado
29 Turning Point Center for Youth Residential Child Care Facility
July I,2011 —June 30, 2012 Therapeutic Residential Child Care Facility
Fort Collins, Colorado
30 Whimspire CPA Child Placement Agency Services
July 1,2011 —June 30, 2012 Child Residential Habilitation Program
Montrose, Colorado
31 Youth Villages Residential Child Care Facility
July I, 2011 —June 30, 2012 Memphis, Tennessee
If you have any questions, give me a call at extension 6510.
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
20$I JUL -8 A IO I4
❑ CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
Z 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY(TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this J day of T Iy 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
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SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
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SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
�4 Eta WELD COUNTY
DEPARTMENT OF
1 iii 1♦� HUMAN SERVI ES�` �
og
By: L./ -4 ri `1� rIJ r �� B : / 2
De ty Clerk to th- C i'S..,� � Chair ignature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT A.M. Group Home
OF HUMAN SERVICES 509 N Sholdt Dr
Platteville, CO 80651
By: By:
irect
11 &70// /27
SS-23A revised 2/09
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A c// J(/( /
027
❑ CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
❑ GROUP HOME/GROUP CENTER CARE
❑ INDEPENDENT LIVING
O PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
Z RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE
❑ SUBSIDIZED ADOPTION
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this l day of Mu, between the Weld
County Department of Social/Human Services hereinaftkr 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 `�G/%—O7/9'
SS-23A revised 2/09 �=�" /
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
E a DEPARTMENT OF
�` HUMAN SERVICES
l n,, i
1861 ... ,
4
1-
De, y Clerk to the�: �' ` , Chair ignatur
+►�(TN'
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Alternative Homes For Youth
OF HUMAN SERVICES PO Box 9
Dacono, CO 80514
By: By:
'rector
11 (9O//c?/9
SS-23A revised 2/09
r,
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
2011 JUL 2b A ' S
❑ 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
Za l k
THIS AGREEMENT, made this 2-0 day of wly between the Weld
County Department of Social/Human Services hereinafter 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
I
SS-23A revised 2/09 aC/i- 07 /27
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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.
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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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
I. 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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•
(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
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
,t\ EL ,S DEPARTMENT OF
HUMAN SERVICES
IS61 t 452
BY .rj A 71,9_,A-,
De ty Clerk to , Chair ignatur
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Attention Homes
OF HUMAN SERVICES 3080 Broadway, Suite C
Boulder, CO 80304 ,I
•
By: By, Ni)
D'r ctor
I1
U����' /
SS-23A revised 2/09 9 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this I day of JI IA between the Weld
County Department of Social/Human Services hereinaftet 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 ar%/—a/s�
SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
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SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
E 1Les HUMAN SERVICES
By: a. ... v .c eiki2�I B • /
Dep I y Clerk tot ®d . . / Chair S nature
git�I AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT M Group Home
OF HUMAN SERVICES 1920 1st Ave
Gree y, CO 80634
By: •
D rector
11 0?()„ .m.,2/9>
_ /9>
SS-23A revised 2/09
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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this 1 day of v Eli between the Weld
County Department of Social/Human Services hereinaftef 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 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 Agency, Residential Child
Care Facility, certified Psychiatric Residential Treatment Facility, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
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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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
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SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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 finds,
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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
•
(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
confonn 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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
,t\ E L6 DEPARTMENT OF
tHUMAN SERVICES
D 1432
By: ,,. B !joja i t / /A
De+ ty Clerk to t- 'L :W C� Chair ignatur
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Cathedral Home for Children
OF HUMAN SERVICES PO Box 20
Lara 'e WY 82073-052
By: By:
i ctor
11
SS-23A revised 2/09 L9(-7/-0 /92
AGREEMENT TO PURCHASE elk JOI
OUT-OF-HOME PLACEMENT SERVICES 8/7
SS23A 9 yy
❑ 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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this t day of J between the Weld
County Department of Social/Human Services hereinafter 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
0// /97
SS-23A revised 2/09 C9
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHAP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
.
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
•
•
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
HUMAN SERVICES
•
By: .� %r' / B • ,)I,AII--O --
Dept Clerk to the ��� �' °� � Chair ignature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Denver Children's Home
OF HUMAN SERVICES 1501 Albion Street
Denver, CO 80220
•
1 ��
By: By:--ewe, Q>thr
D rector
11
SS-23A revised 2/09 q2G//--a/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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this 1 day of t) between the Weld
County Department of Social/Human Services hereinafte 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 co/A- 2/27
SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF services
and shall document any court ordered treatment including identifying the agency
responsible for providing the court ordered treatment.
E 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, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
I� ► �` HUMAN SERVICES
La • 1861 tr
Dep y Clerk to the� �.:* Chair S'gnature
ei 1> AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Devereux Cleo Wallace
OF HUMAN SERVICES 8405 Church Ranch Blvd
Westminster, CO 80021
��/
By: By: `� A,,,(J ( c /L—
i ector
11
SS-23A revised 2/09 A�0l� / >
AGREEMENT TO PURCHASE Cry
OUT-OF-HOME PLACEMENT SERVICES
SS23A
9Q
•
❑ 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS AGREEMENT, made this II day of between the Weld
County Department of Social/Human Services hereinaftek 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 07C//- 197
SS-23A revised 2/09 RECEIVED LUI
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
,t,\\ IG A1 DEPARTMENT OF
HUMAN SERVICES
tcasza
By: ���. ,...:,�: �._: A ILA1/✓
Deput Clerk to the B J is)/ Chair ignature/
�wr�I
AUG 1 0 2011
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.4_ t `_
it ector
11
SS-23A revised 2/09 t5?0//-c7V9 2
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
2011 JUL -1 A 9: 48
El CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
El 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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this ( day of pa between the Weld
County Department of Social/Human Services hereinafter ailed "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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
SS-23A revised 2/09 a(ft 01/9/
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
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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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
Itiai`4 y1♦. HUMAN SERVICES
B ,® 11
�e .� B ��L✓f�N
De ty Clerk to tie Boar Chair Sig ature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Excelsior Youth Centers
OF HUMAN SERVICES 15001 E. Oxford Ave
Aurora, CO 80014
By: By: Oke
irector
7tme5 LU tc,iik_-Dv/Lay-tau 8(.."1frwO te✓Cltykoerty
asu.rk A'dwlsctt.C
11 aQ// 19 7
SS-23A revised 2/09
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)
►1 RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE
❑ SUBSIDIZED ADOPTION
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this ( day of Uui between the Weld
County Department of Social/Human Services hereinafter'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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
I ,?[ri//a/92
SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year,June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
I. 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, and CI-IRP 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
HUMAN SERVICES
t 11161 4. I-11/2
wa �
B ��.
Dep ty Clerk to the l` rl Chair ignature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Families First
OF HUMAN SERVICES Children's Treatment Center
2163 South Yosemite St
Denver, CO 80231
By: By: A.
Di•ector
11 q7 65//- �/9 --
SS-23A revised 2/09
• AGREEMENT TO PURCHASE Zell
OUT-OF-HOME PLACEMENT SERVICES
SS23A 819 13 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
Z THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this I day of Jt between the Weld
County Department of Social/Human Services hereinafter called "County" and Griffith
Centers for Children Inc.,8461 Turnpike Drive, Suite 100, Westminster, CO 80031,
hereinafter called"Contractor." THIS AGREEMENT, shall include all children placed
by the Weld County Department of Social/Human Services and Griffith Centers for
Children 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 q s7
SS-23A revised 2/09 ���� 1/ /
•
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,
2011, until the end of the Colorado fiscal year,June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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,
r ON BEHALF OF THE
WELD COUNTY
I`#4 IE llaa DEPARTMENT OF
HUMAN SERVICES
AV
By: Si. . ` .. _1 r ate.:.: � B : I j
De ty Clerk to th Et N1<>1 Chair ignature
AUG 1 0 7011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Griffith Centers for
OF HUMAN SERVICES Children Inc.
8461 Turnpike Drive, Ste 100
Westminster, CO 80031
By: By: `7/I6/l1
D rector
11 2
SS-23A revised 2/09 ��C��— �?
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
2011 JUL -13 Ala OI
® 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this/� ! day o r / between the Weld
County Department of Social/Human Service r fter called "County" and Heritage
House, PO Box 195, Louisville,CO 80027, ereinafter called "Contractor." THIS
AGREEMENT, shall include all children placed by the Weld County Department of
Social/Human Services and Heritage 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
E La DEPARTMENT OF
®`� HUMAN SERVICES
E
t1- $)
By: B rDe',fity Clerk tot l:: ti� Chair S gnature
Wit AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Heritage House
OF HUMAN SERVICES PO Box 195
Louisville, CO 80027
By: By: Qy
trector
11
SS-23A revised 2/09 acl/.- O7/27
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES t b
SS23A ry
Oe
® 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this 1 day of S between the Weld
County Department of Social/Human Services hereinafte 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
SS-23A revised 2/09 (1/`0V�7
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,
2011, until the end of the Colorado fiscal year,June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
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SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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: Wel County CI l the Board WELD COUNTY BOARD
OF SOCIAL SERVICES,
ON BEHALF OF THE
loosars% WELD COUNTY
` s/ 4 % DEPARTMENT OF
%, DEPARTMENT
HUMAN SERVIC S
BY: STM11.-1 J yt X r y _ .�I. • A it.- ,htv A-
Debuty Clerk to "e Boti`( / r Chair Si nature
•
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Imagine
OF HUMAN SERVICES 1400 Dixon Ave
�Lafayette, CO 80026
By: By:(�"
D ector
11
SS-23A revised 2/09 &(//- `9
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
' MI JUL 12 A ID 514
❑ 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this / day of jai between the Weld
County Department of Social/Human Services hereinaftercalled "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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
SS-23A revised 2/09 1 (9r)//-07121)
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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.
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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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
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SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
,f\� E ft /�` , HUMAN SERVICES
1861 PP
•�
By: •�� v �, _. B '
Dep y Clerk to t Chair ignatur
UO \ AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Jefferson Hills
OF HUMAN SERVICES 421 Zang St
Lakewood, CO 80228
(J
By: By.• - Cu 4a41.7.4_,
-
rector n
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11 CY/-�/2
SS-23A revised 2/09 a
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
❑ CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
Z 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY(TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this / day of jail between the Weld
County Department of Social/Human Services hereinaftdr called"County" and Kids
Crossing, 1440 E Fountain Blvd,Colorado Springs, CO 80910-3502, hereinafter
called"Contractor." THIS AGREEMENT, shall include all children placed by the Weld
County Department of Social/Human Services and 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 o?O//-x/27
SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
5 OF SOCIAL SERVICES,
ON BEHALF OF THE
WELD COUNTY
DEPARTMENT OF
E L/A ` HUMAN SERVICES
:so iK_ 1♦ •
By: cyrLa. \ n.
De r1 ty Clerk to t�s.�i .• ) Chair gnature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Kids Crossing
OF HUMAN SERVICES 1440 E Fountain Blvd
Colorado Springs, CO 80910
By: By:
Dir ctor
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SS-23A revised 2/09 aD//-?%2y
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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this G day of J J\11..�� d5I ( between the Weld
County Department of Social/Human Services hereinaftkr 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
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SS-23A revised 2/09 (9eW-.7/9�
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
a
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
EL % HUMAN SERVICES
•
Masi I -.4tv /
By: ]. _�. \� > � ',. FL- /�_/J1.`,
D:1 uty Clerk to t s �< , Chair ignature /
AUG 1 0 2011
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: BC
Di ctor
11
SS-23A revised 2/09 0?Cti//'°V/97
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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this j day of U w� between the Weld
County Department of Social/Human Services hereinaftet 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 eii-o2i7
SS-23A revised 2/09
•
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
•
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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,
E ON BEHALF OF THE
WELD COUNTY
DEPARTMENT OF
E .A,,�` HUMAN SERVICES
1361 "Oaf
By: �.. L i. .. �P41, i 1/ $íwL
D:i ty Clerk to e : t Chaiure/
U N't AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Maple Star Colorado
OF HUMAN SERVICES 2785 Speer Blvd, Suite 340
Denver, CO 80211
By: Bat
Dir ctor
11 c9D//-c2/.7
SS-23A revised 2/09
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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this I day of T between the Weld
County Department of Social/Human Services hereinafte 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
SS-23A revised 2/09 0?C`//-(9/9?
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
E,pt\� /,�� HUMAN SERVIC S
j 1861 1' `; '5*%v;
By: - �, �. .. , .1 �� : : l ti
De y ty Clerk t Chair ignature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Marie Alirez Group Home
OF HUMAN SERVICES 1405 26th Street
Greeley, CO 80631
By: By: AN ,.Je
i ector
11 p,7O//-d/9.SS-23A revised 2/09
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
❑ CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
/1 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS AGREEMENT, made this I day of J between the Weld
County Department of Social/Human Services hereinaft 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
C//-.;?/2';
"l/f
SS-23A revised 2/09 i
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements the negotiated rate
or the approved vendor rate; and, for CHAP 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
Elsa
c•cei HUMAN SERVICES
1861 .. ThSzoat
By: ai� �. ti- \ �t, S' .!� / l ^_
D.l,uty Clerk t'�he B r. : Chai gnature
♦®(gyp 1-t ! AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Michael Alirez Group Home
OF HUMAN SERVICES 1709 37th Ave
Greeley, CO 80634
By: By:
ector
11
SS-23A revised 2/09 �C�� � 7
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A dee
22
.4 R
❑ 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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this j day of t� between the Weld
County Department of Social/Human Services hereinaft r called "County" and Mount
St. Vincent Home,4159 Lowell Blvd, Denver,CO 80211, hereinafter called
"Contractor." THIS AGREEMENT, shall include all children placed by the Weld
County Department of Social/Human Services and Mount St. Vincent 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
SS-23A revised 2/09 ae// ` j
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,
2011, until the end of the Colorado fiscal year,June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
•
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
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SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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.
I I. 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
•
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
jEZ �`` HUMAN SERVICES
B� puty Clerk h: p� Chair S' nature
F�'€� y AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Mount St. Vincent Home
OF HUMAN SERVICES 4159 Lowell Blvd
Denver, CO 80211 �\
By: By:
tt4orQtt
11
SS-23A revised 2/09 c2C//—4/99 7
s
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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this I Q-, day of (3 ii tqq 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 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,
WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child
Care Facility, certified Psychiatric Residential Treatment Facility, Therapeutic
cc_o1 A ..wiro,a 9 O 1 ����- c:-?/9
Residential Child Care 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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
E Z<CD HUMAN SERVICES
By:
De ty Clerk to th: :� . �� _ � Chair Signature
irm
`* ' AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Mountain Crest Poudre
OF HUMAN SERVICES Valley Health Care Inc.
D/B/A Poudre Valley Hospital
4601 Corbett DR
Fort Collins, CO, 80528
By: By: N61,a ,111,a,,,,,i4n I Coo
Di actor
11 v?O//-ca/9'"
SS-23A revised 2/09
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
• THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS AGREEMENT, made this I day of OC-Iibetween 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
SS-23A revised 2/09 (-4 C-"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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements,the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
1E,las HUMAN SERVICES
/ ' r 1861 ' s'O By: B
De L$ty Clerk tot Chair gnature
U N't AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Reflections For Youth, Inc.
OF HUMAN SERVICES PO Box 1860
Berthoud CO 80513
By: By:
Dir for
11 _ Q
SS-23A revised 2/09 O�� a /91-7
•
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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
2�ttAC
THIS AGREEMENT, made this day of between i e
{,,: ,_ of the University or
o,a body corporate. t,
County Department of Social/Human Services hereinafter called "County" an.. .► behalf of the Universit.
Itaversity of Colorado Health Sciences Center-dba Synergy,3738 W Prin6Eu***enver.
Denver, CO 80236, hereinafter called "Contractor." THIS AGREEMENT, shall include
all children placed by the Weld County Department of Social/Human Services and The
University of Colorado dba Synergy.
D-elnYer-
A child specific addendum, identifyi : mi i i ual service needs, must be completed and
attached to supplement this agreement .ch 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
I
Sca
SS-23A revised 2/09 I O�� �3-il-// ( 1)//-(:)2/9
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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,
�J�6*.•�___ ON BEHALF OF THE
WELD COUNTY
DEPARTMENT OF
E A�` HUMAN SERVIC S
p ♦NAB
1861 (':'t'=
By:c ?nn; 4 r�S ■ .� ,:'. B • A 7 1_
•
eputy Clerk the���- � Chair ignatur
`® , ,./ AUG 1 0 2011
Approval as to Substance: CONTRACTOR R ents of the University(
WELD COUNTY DEPARTMENT �1�'L� boddyy
OF HUMAN SERVICES entegf don fair of thhe Unive
dba Synergy Denver.
3738 W Princeton Cir
Denver,
CO 80236 / 1
By: By: 61A. tt_4 7/)51)
Dir etor
Christine Aheam
Assistant Director
Office of Grants and Contracts
11 r�
SS-23A revised 2/09 &C//- /9 /
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT
l,MENT SERVICES Ip
E I
ElCHILD PLACEMENT AGENCY SERVICES (CPA) I 0
Z CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
❑ GROUP HOME/GROUP CENTER CARE
El INDEPENDENT LIVING
❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
® RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE
❑ SUBSIDIZED ADOPTION
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
El TRANSITION/HOME BASED AFTER-CARE (RCCF)
El OTHER (DESCRIBE):
THIS AGREEMENT, made this I day of tialy between the Weld
County Department of Social/Human Services hereinaftef 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
d�
SS-23A revised 2/09 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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, RCCFs or group homes except PR1'F. 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
. .
(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
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
E '® DEPARTMENT OF
`�` HUMAN SERVICES
•
. 1861
By: .—.emu •�B • A le4
Deput Clerk to the �p1 7 Chair ignature
UN1 AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Roundup Fellowship
OF HUMAN SERVICES 2250 S Oneida, Suite 201
Denver, CO,O,80224 74.4‘64.W
By: By: 1ZP.al VG4` l 1//jtyt-t
Di& tTh 'f
or U
11
SS-23A revised 2/09 (>70//—E-1/9->
AGREEMENT TO PURCHASE jay
OUT-OF-HOME PLACEMENT SERVICES ✓(/t
SS23A <16
® CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ CHILD RESIDENTIAL HABILITATION PROGRAM (CHAP)
® 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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS AGREEMENT, made this 1 day of J between the Weld
County Department of Social/Human Services hereinaft r 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1
SS-23A revised 2/09 ,?C//—,x/92
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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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
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.
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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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
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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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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(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
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
'an3/4 WELD COUNTY
N. EL % DEPARTMENT OF
F O\ HUMAN SERVICES
1 '861 ..N ��
By: C_ �J1cyi`A, ''`:i� 4P ' i t?� 1)-'
Dep Clerk to the :4, ® %'e Chair S. nature /
S N die AUO 10 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Savio House
OF HUMAN SERVICES 325 King St
Denver, CO 80219
By: By:
Dir ctor
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e
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES /✓U( //
SS23A 4
?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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this ( day of S between the Weld
County Department of Social/Human Services hereinafte 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 7 l
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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,
2011, until the end of the Colorado fiscal year,June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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SS-23A revised 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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SS-23A revised 2/09
(2) All billing by the contractor must be in a format approved by the fiscal agent
. of 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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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SS-23A revised 2/09
(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
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
rlu.r,� WELD COUNTY
III Eta, \ DEPARTMENT OF
HUMAN SERVICES
• ism 7.):6):1"J-,
te
Depll y Clerk to t•e Bo.�'' $ '
®f(l it r%-±? Chair ignature
,, . ., AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Special Kids Special Families
OF HUMAN SERVICES 424 W Pikes Peak Ave
Colorado Springs, CO 80905
7-2)
B :
By: 7 6_
Y � /!-
4tory
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11
ac//-
SS-23A revised 2/09 ��,
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)
Z RESIDENTIAL CHILD CARE FACILITY (RCCF)
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
❑ SHELTER CARE rY
❑ SUBSIDIZED ADOPTION
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF) �-t
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF) s
❑ OTHER (DESCRIBE):
0
THIS AGREEMENT, made this day N
of � between the Weld
County Department of Social/Human Services hereinafter 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 a67/-02/92
SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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: Count ' the Board WELD COUNTY BOARD
OF SOCIAL SERVICES,
ON BEHALF OF THE
WELD COUNTY
o!a`'s DEPARTMENT OF
� �
� ��N HUMAN SERVICES
Iasi0.0
flannel"By: .M „.0`71/, ill, t, • 0/y ,/ /to
DepLty Clerk to he B / Chair ignature
i• r : V V ' AUG 102011
♦
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Tennyson Center
OF HUMAN SERVICES for Children
2950 Tennyson St
Denver, CO 80212-3029
By: By: ` (r� 3
Di r ctor tit(
11 o//-,2 19 `,
SS-23A revised 2/09
4
O
A,
AGREEMENT TO PURCHASE jO
OUT-OF-HOME PLACEMENT SERVICES is
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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this I day of OT between the Weld
County Department of Social/Human Services hereinaft r 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 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 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 (:)?C'//-07/9i
SS-23A revised 2/09 t
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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: Wel County Cle the Board WELD COUNTY BOARD
OF SOCIAL SERVICES,
ON BEHALF OF THE
WELD COUNTY
Ioni'ibb DEPARTMENT OF
f, \\ E +a• HUMAN SERVICES 361 (1 BY: -.ZYw. A, a s,
De y ty Clerk tot e Coal ? ,' Chair signature
, bre/ ' > AUG 102011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Third Way Center
OF HUMAN SERVICES PO Box 61385
Deny , O 80206
By: By:
Dir for
11
SS-23A revised 2/09 '�1� 19,
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A 2011 JUL -1 A 43
❑ 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
® THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this I day of J,,ty, between the Weld
County Department of Social/Human Services hereinafterkalled "County" and Turning
Point Center for Youth, 1644 South College Ave, Fort Collins, CO 80525, hereinafter
called "Contractor." THIS AGREEMENT, shall include all children placed by the Weld
County Department of Social/Human Services and Turning Point Center 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 C// �J9
SS-23A revised 2/09 7
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
2
SS-23A revised 2/09
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 2/09
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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
4
SS-23A revised 2/09
e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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
SS-23A revised 2/09
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, TRCCFs, 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
6
SS-23A revised 2/09
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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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
SS-23A revised 2/09
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 TRCCF, 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 TRCCF,
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 TRCCF, 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
8
SS-23A revised 2/09
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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
9
SS-23A revised 2/09
(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
10
SS-23A revised 2/09
(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
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
(El+ci HUMAN SERVICES
1 I861 dt')G IlC. e
S7
Deity Clerk to the �a Jai Chair ignature/
®Uri1 AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Turning Point Center
OF HUMAN SERVICES for Youth
1644 South College Ave
Fort Collins, CO 80525
By: B
Dir for �
c=xcC v n t-E .-Jr ea-0_7-612
11 (90//- 02/22
SS-23A revised 2/09
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
® CHILD PLACEMENT AGENCY SERVICES (CPA)
® CHILD RESIDENTIAL HABILITATION PROGRAM (CHRP)
IT 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER (DESCRIBE):
THIS AGREEMENT, made this I day of lJ between the Weld
County Department of Social/Human Services hereinafte called "County" and
Whimspire CPA, 2305 S Townsend, Montrose, CO 81401, hereinafter called
"Contractor." THIS AGREEMENT, shall include all children placed by the Weld
County Department of Social/Human Services and 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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
SS-23A revised 2/09 0.7C//—(>2 /27
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,
2011, until the end of the Colorado fiscal year, June 30,2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
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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 TRCCF and CHRP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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•
(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
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
L�1 WELD COUNTY
�� DEPARTMENT OF
HUMAN SERVICES
Ism 1 •
1.,
By: 414,,, ebi„,„-
Dept y Clerk to the : ,are'* � � Chair Signature
AUG 10 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Whimspire CPA
OF HUMAN SERVICES 2305 S Townsend
Montrose, CO 81401
By: By:
��-
Dir ctor
l'Serel }4 " \& n
11 020W-62/97
SS-23A revised 2/09
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES 2671 j/J 19
SS23A ,il) 9
Ye
❑ 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
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ TRANSITION/HOME BASED AFTER-CARE (RCCF)
❑ OTHER(DESCRIBE):
THIS AGREEMENT, made this r day of J between the Weld
County Department of Social/Human Services hereinaft called "County" and Youth
Villages,PO Box 341154, Memphis, TN 38184-1154, hereinafter called"Contractor."
THIS AGREEMENT, shall include all children placed by the Weld County Department
of Social/Human Services and Youth Villages.
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, Therapeutic
Residential Child Care Facility, or meets the requirements for other licensed service
types.
1 o27 t e /9.7SS-23A revised 2/09
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,
2011, until the end of the Colorado fiscal year, June 30, 2012. 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 TRCCF placements, the established Fee-for-Service rate and
the negotiated rate or the approved vendor rate; for RCCF placements 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
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SS-23A revised 2/09
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.
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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
TRCCFs, 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
TRCCFs, 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 TRCCF services are necessary to meet the needs of the child
and to treat the child's current diagnosis.
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e. Identify the provision of, or the referral for, services other than TRCCF 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;
h. Anticipated date for discharge from treatment purchased for the child.
i. A permanency goal for the child.
5. Monthly, Child Placement Agencies, TRCCFs, 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.
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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, TRCCFs, 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
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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 TRCCF and CI1RP shall be made to either
the MMIS System or the County. Billings for RCCFs, 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.
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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 TRCCF, 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 TRCCF,
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 TRCCF, 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
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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.
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 TRCCF therapeutic programs and CHRP placements 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, TRCCF, 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.
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(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
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, TRCCFs, RCCFs, and CPAs must be completed
and a copy provided to the Colorado Department of Human Services (Attn:
Administrator for PRTFs, TRCCFs 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.
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(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
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.
isititt%4,eld County Clerk to the Board WELD COUNTY BOARD
\` • / tor OF SOCIAL SERVICES,
ON BEHALF OF THE
Iasi 1/44., WELD COUNTY
rrn, /:�;,:o ` DEPARTMENT OF
HUMAN SERVICES
,‘11
410...r rr0 •
By: kt:� v� t� B ' IA)! Q obi
De.} y Clerk to thgloard Chair ignature
AUG 1 0 2011
Approval as to Substance: CONTRACTOR
WELD COUNTY DEPARTMENT Youth Villages
OF HUMAN SERVICES PO Box 341154
Memphis, TN 38184-1154
•
By: By. ate
Dir for
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