HomeMy WebLinkAbout20072443.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - SIGNAL BEHAVIORAL HEALTH NETWORK
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with a Child Protection Agreement for Services
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Social Services, and Signal
Behavioral Health Network, commencing June 1, 2007, and ending May 31, 2008, with further
terms and conditions being as stated in said agreement, and
WHEREAS,after review, the Board deems it advisable to approve said agreement, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services, that the Child Protection Agreement for
Services between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Social Services, and Signal
Behavioral Health Network be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said agreement.
The above and foregoing Resolution was,on motion duly made and seconded, adopted by
the following vote on the 6th day of August, A.D., 2007, nunc pro tunc June 1, 2007.
ologn"3/4.� BOARD OF COUNTY COMMISSIONERS
i,\4 S ! /L ‘ WELCOUN , COLORADO
ATTEST: , iii- t eipavid E. Long, Chair
Weld County Clerk to the - •.-
VL EXCUSED
an f / Wit( . Jtrke, - m
DeC Cle o the Board / (V�
Wil iam F. Garcia
AP ED AST k -�
� Robert D. Masden
ounty Attorney c--t-A-A, �i da, ,.Q1 !,1-/—
Douglas'Rademacher
Date of signature: 6.067
2007-2443
SS0034
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DEPARTMENT OF SOCIAL SERVICES
P.O. A BOX
GREELEY, CO. 80632A
Website: www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
IIIID O
COLORADO
MEMORANDUM
TO: David E. Long, Chair Date: August 1, 2007
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services ,t,Ct3CL,
RE: Child Protection Agreement for Services 2.
tweenJSignal Behavioral Health
Network and the Weld County Department of Social Services
Enclosed for Board approval is a Child Protection Agreement for Services between Signal
Behavioral Health Network(Signal)and the Weld County Department of Social Services
(Department). This Agreement was reviewed at the Board's Work Session held on July 23, 2007.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is June I, 2007 through May 31, 2008.
2. The Department agrees to reimburse Signal, on behalf of Island Grove Regional
Treatment Center a maximum total of$300,000 including an administrative fee of
$15,000 and according to a fee schedule.
3. Signal will provide assessments, monitored sobriety services, and treatment according to
Signal's fee schedule and through their provider, Island Grove Regional Treatment
Center.
4. The source of funding is Core Services.
If you have any questions, please telephone me at extension 6510.
2007-2443
PY-0708-CORE-102 �� C
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND SIGNAL BEHAVIORAL HEALTH NETWORK
This Agreement,made and entered into the I'1'day of 2007,by and between the Board of Weld
County Commissioners,sitting as the Board of Social Services,on behalf of the Weld County Department of Social
Services,hereinafter referred to as"Social Services,"and Signal Behavioral Health Network,referred to as"Signal".
WITNESSETH
WHEREAS,required approval,clearance,and coordination have been accomplished from and with appropriate
agencies;and
WHEREAS,the Colorado Department of Human Services has provided Colorado Core Services substance abuse
treatment funding to Social Services for outpatient and residential core services for families,children,and adolescents;
and
WHEREAS,Social Services requires the services of a substance abuse treatment provider to assist Social
Services to deliver substance abuse treatment services to child welfare clients,and Signal is willing and able to provide
such services; and
WHEREAS,Signal is a Colorado non-profit corporation organized for the purpose of managing and
coordinating high quality,cost efficient,integrated chemical dependency and related behavioral health care services in the
State of Colorado.
NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
This Agreement shall become effective on June 1,2007,upon proper execution of this Agreement and shall
expire May 31,2008.
2. Scope of Services
Signal network providers shall provide services to any person(s)eligible for child protection services in
compliance with Exhibit A,"Scope of Services,"a copy of which is attached by reference.
3. Payment
A. Payment shall be made on the basis of Exhibit B,"Payment Schedule,"Exhibit C,"Core Services Fee
Schedule,"and Exhibit E,"Standards of Responsibility for Core Services"and shall not exceed three-
hundred thousand dollars($300,000.00),copies of which are attached hereto and incorporated herein
by reference.
"Payment Schedule"shall establish the maximum reimbursement,which will be paid from Colorado
Core Services substance abuse treatment funding during the duration of this Agreement. Signal,in
accordance with federal HIPPA regulations,has adopted the standard transaction code set for all
treatment services on or before October 16,2003.
B. Signal shall submit an itemized monthly bill to Social Services for all costs incurred and services
provided pursuant to Exhibit A of this Agreement in accordance with criteria established by Social
Services and Signal. Requests to modify criteria must be provided with 30 days advance notice.
Signal shall submit all itemized monthly billings to Social Services no later than the 3`'Wednesday of
the month following the current month plus the previous 60 days for the month the cost was incurred in
accordance with the Trails payroll calendar.
C. Signal shall make available,on its web site,monthly billing reports in accordance with the billing
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criteria established by Social Services no later than the 3`d Wednesday of the month following the
month of service. Monthly client progress reports must be made available to the Core Services
Caseworker,in the format provided by the Department(see attached Exhibit G). In the alternative,the
information contained on Exhibit G will be available to the Core Services Caseworker for download
from the Signal database by the 3rd Wednesday of the month following the date of service. Island
Grove Regional Treatment Center will be required by Signal to input the monthly progress information
into the Signal database prior to their ability to bill service charges for that client. Any incomplete
progress report will be deemed incomplete and all such associated services will be pended.
Failure to submit monthly billings and/or monthly client reports in accordance with the terms of this
agreement may result in Signal's forfeiture of all rights to be reimbursed for such expenses. In the
event of a forfeiture of reimbursement, Signal may appeal such circumstance to the Director of Social
Services,after all remedies described in Item 11,A of the Agreement are exhausted. The Director of
Social Services shall render a decision. The decision of the Director of Social Services may be
appealed to the Board of County Commissioners according to the provisions of Item 11 of the
Agreement.
D. Payments of costs incurred pursuant to this Agreement are expressly contingent upon the availability of
Colorado Core Services substance abuse treatment funding to Social Services.WCDSS shall be liable
for all services authorized and provided up to the date of receipt by Signal of revocation of such
authorization.
E. Social Services shall not be billed for,and reimbursement shall not be made for,time involved in
activities outside of those defined in Exhibit A,"Scope of Services"and Exhibit C,"Core Services Fee
Schedule." Work performed prior to the execution of this Contract shall not be reimbursed or
considered part of this Agreement.
F. Signal shall provide training and technical support,as necessary and as resources allow, for Social
Services staff in accessing Signal's data and billing reports and on the use of the child welfare referral
system.
4. Financial Management
At all times from the effective date of this Contract until completion of this Contract, Signal shall comply with
the administrative requirements,cost principles and other requirements set forth in the Financial Management
Manual adopted by the State of Colorado. The required annual audit of all funds expended under the Child
Welfare Services and Family and Children's Program funding must conform to the Single Audit Act of 1984 and
OMB Circular A-133.
5. Payment Method
Unless otherwise provided in the Scope of Services and Payment Schedule:
A. Signal shall provide proper monthly invoices,make available monthly progress reports for each client incurring
charges,and verification of services performed for costs incurred in the performance of the agreement.
B. Social Services may withhold any payment if Signal has failed to comply materially with the Financial
Management Requirements,program objectives,contractual terms,or reporting requirements. In the event
of a withhold of reimbursements, Signal may appeal such circumstance to the Director of Social Services,
after all remedies described in Item 11,A of the Agreement are exhausted. The Director of Social Services
shall render a decision. The decision of the Director of Social Services may be appealed to the Board of
County Commissioners according to the provisions of Item I I of the Agreement.
C. WCDSS will complete the Signal remittance advice and return to Signal within 5 business days of
completion of each month's TRAILS payroll date. Each remittance advice shall detail reasons for denial of
any and all services. WCDSS shall work with Signal and other counties to develop standard claims denial
criteria. WCDSS shall reimburse Signal for all complete services invoiced within 45 calendar days from the
date of receipt of Signal's invoice.
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D. WCDSS shall identify the individuals Signal should communicate with for clinical,data and billing needs.
6. Assurances
Signal shall abide by all assurances as set forth in the attached Exhibit D,which is attached hereto and incorporated
herein by reference.
7. Compliance with Applicable Laws
At all times during the performance of this contract, Signal shall strictly adhere to all applicable federal and state
laws,orders,and all applicable standards,regulations,interpretations or guidelines issued pursuant thereto. This
includes the protection of the confidentiality of all applicant/recipient records,papers,documents,tapes and any
other materials that have been or may hereafter be established which relate to the Contract. Signal acknowledges
that the following laws are included:
Title VI of the Civil Rights Act of 1964,42 U.S.C.Sections 2000d—1 et seq.and its implementing
regulation,45 C.F.R.Part 80 a seq.;and
Section 504 of the Rehabilitation Act of 1973,29 U.S.C. Section 794,and its implementing regulations,45
C.F.R.Part 84;and
- the Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et.seq.and
its implementation regulations,45 C.F.R.Part 91;and
Title VII of the Civil Rights Act of 1964;and
- the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
the Education Amendments of 1972;and
Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
All regulations applicable to these laws prohibiting discrimination because of race,color,national origin,and
sex,religion and handicap,including Acquired Immune Deficiency Syndrome(AIDS)or AIDS related
conditions,covered under Section 504 of the Rehabilitation Act of 1973,as amended,cited above. If necessary,
Signal and Social Services will resist in judicial proceedings any efforts to obtain access to client records except
as permitted by 42 CFR Part 2. Social Services and Signal shall sign a Qualified Service Organization
Agreement in compliance with 42 CFR Part 2,and attached hereto as Exhibit F.
Included is 45 C.F.R.Part 74 Appendix G 9,which requires that affirmative steps be taken to assure that small
and minority businesses are utilized,when possible,as sources of supplies,equipment,construction and services.
This assurance is given in consideration of and for the purpose of obtaining any and all federal and/or state
financial assistance.
Any person who feels that s/he has been discriminated against has the right to file a complaint either with the
Colorado Department of Human Services or with the U.S.Department of Health and Human Services,Office for
Civil Rights.
8. Certifications
Signal certifies that,at the time of entering into this Contract,it has currently in effect all necessary licenses,
approvals,insurance,etc. required to properly provide the services and/or supplies covered by this contract.
9. Monitoring and Evaluation
Signal and Social Services agree that monitoring and evaluation of the performance of this Agreement shall be
conducted by Signal and Social Services. The results of the monitoring and evaluation shall be provided to the
Board of Weld County Commissioners and Signal.
Signal shall permit Social Services,and any other duly authorized agent or governmental agency,to monitor all
activities conducted by Signal pursuant to the terms of this Agreement. As the monitoring agency may in its sole
discretion deem necessary or appropriate, such program data, special analyses,on-site checking, formal audit
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examinations,or any other reasonable procedures. All such monitoring shall be performed in a manner that will
not unduly interfere with agreement work.
10. Modification of Agreement
All modifications to this agreement shall be in writing and signed by both parties.
11. Remedies
A. Signal and Social Services shall exhaust all remedies as provided in Exhibit E,"Standards of Responsibility
for Core Services",prior to the remedy provided in Item 11,B,of this Agreement.
B. The Director of Social Services or designee may exercise the following remedial actions should s/he
find Signal substantially failed to satisfy the scope of work found in this Agreement. Substantial failure
to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by
Signal. These remedial actions are as follows:
1) Provide reasonable advance written notice of perceived failure to satisfy the scope of work.After
Signal receives such notice and a reasonable opportunity to cure WCDSS may withhold payment
of Signal until the necessary services or corrections in performance are satisfactorily completed;
and
2) Deny payment or recover reimbursement for those services or deliverables,which have not
been performed and which due to circumstances caused by Signal cannot be performed or if
performed would be of no value to the Social Services. Denial of the amount of payment shall
be reasonably related to the amount of work or deliverables lost to Social Services;and
3) Incorrect payment to Signal due to omission,error,fraud,and/or defalcation shall be recovered
from Signal by deduction from subsequent payments under this Agreement or other agreements
between Social Services and Signal,or by Social Services as a debt due to Social Services or
otherwise as provided by law.
C. Signal may appeal the decision of the Director of Social Services or designee,as provided in Item 11,B,of
the Agreement,by submitting,within thirty(30)calendar days of the Director's action,and basis of such
appeal to the Board of County Commissioners.
12. Representatives
For the purpose of this Agreement,the individuals identified below are hereby designated representatives of the
respective parties. Either party may from time to time designate in writing a new or substitute representative(s):
For Social Services:
Gloria Romansik Social Services Administrator
Name Tide
For Signal:
Bill Wendt Chief Executive Officer,Signal
Name Title
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13. Notice
All notices required to be given by the parties hereunder shall be given by certified or registered mail to the
individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute
person(s)or address to whom such notices shall be sent:
To: Social Services To: Signal
Judy A.Griego,Director Bill Wendt,CEO
P.O.Box A 1391 Speer Blvd.,Suite 300
Greeley,CO 80632 Denver,CO 80204
14. Litigation
Signal shall promptly notify Social Services in the event that Signal learns of any actual litigation in which it is a
party defendant in a case that involves services provided under this Agreement. Signal,within five(5)calendar
days after being served with a summons, complaint,or other pleading which has been filed in any federal or state
court or administrative agency, shall deliver copies of such document(s)to the Social Services Director. The
term"litigation"includes an assignment for the benefit of creditors,and filings in bankruptcy,reorganization
and/or foreclosure.
15. Termination
This Agreement may be terminated at any time by either party given thirty(30)days written notice and is subject to
the availability of finding,subject to the provisions of Item 10 and Item 15. Signal reserves the right to suspend
services to clients if funding is no longer available. Social Services acknowledges financial responsibility for clients
authorized under the terms of the Agreement.
16. Entire Agreement
This Agreement,together with all attachments hereto,constitutes the entire understanding between the parties
with respect to the subject matter hereof,and may not be changed or modified except as stated in Paragraph 10
herein.
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year first
abovewrir . j�j:v pp
+Csta
Al JEST:
Weld County Clerk to the Board : ' C TY OF WELD COLORADO,BY AND THROUGH
1861 OARD OF COUNTY COMMISSIONERS,SITTING
■ .e l�'
� ■ ������r�"� 1 BOARD OF SOCIAL SERVICES FOR THE
By: e��/�, �Y/j;�,r, �p� CO Y DEPARTMENT OF SOCIAL SERVICES
Deputy Cl= to the Bo.
ATTESTING TO BOARD OF COON
COMMISSIONER SiG11Ai NLY By:
David E.Long,Chair 0 6 2001
APP A
County Attorney
APPROVED AS TO UBS CE SIGN UTHORIZED REPRESENTATIVE:
By: By 1' �T aQ 11
J A. r go,Dr or,W County hn T.Brewster,Board 1T ' nt
e artm of Socia ervice Signal Behavioral Health Network
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EXHIBIT A
SCOPE OF SERVICES
A. Assessments
I) Alcohol and Drug Differential Assessment(3-Hours)
Assessment will evaluate alcohol/drug involvement as well as mental health status,history of mental health
issues,sexual history,legal history,and certain standard tests(ASAP,ASAM PPC-2,ASI,SOCRATE,
AODUI,Drinking History Questionnaire,Family Environment Scale)may be given. Signal will provide
two collateral contacts as part of the Assessment.
2) Co-Occurring Alcohol and Drug with Domestic Violence Assessment(3-Hours)
Summary of assessment with recommendations sent to referring agency. The following areas will be
assessed:
Criminal History Profile of Client's Violent
Behaviors
Potential for Violence Mental Health Status
Client's Medical History Substance Abuse History
Suicidal/Psychological/Cultural Milton Test,if needed
History
3) Substance Abuse Forensic Evaluation(3 hours,as staff expertise permits)
A forensic evaluation is specifically geared toward the substance-abusing offender. It involves additional
testing to determine the crimogenic aspect of the person to be taken into consideration when developing
treatment recommendations. Testing will be comprised of CVI,ASUS,SASSI,Milton Clinical Multiaxial
Inventory(MCMI-III),a clinical interview,and a behavioral profile. The testing is cross-referenced with
the clinical interview,and in relation to collateral data.
B. Treatment Options
1) Co-Occurring Alcohol and Drug with Domestic Violence Group Therapy(average length of
treatment,24 to 36 weeks): Groups for both men and women are offered. The group addresses anger
management,healthy relationships,male and female roles,and boundaries. As needed,a Millon Test
may be given,a standardized psychological test which measures functioning level in 22 personality
disorders and clinical syndromes for adults(8th grade reading level: > 18;available in Spanish).
2) Family Therapy(average length of treatment,8 to 16 sessions): Involves two or more family
members and provides therapeutic intervention to improve family communications,functioning,and
relationships. Length of participation is dependent on client goals and progress toward meeting goals.
3) Couples Counseling(average length of treatment,6 to 12 sessions): Utilizes the Brief Strategic
Family Therapy,an evidenced based model supported by SAMSHA. This group will focus on the
familial effects of substance abuse on the couples dynamic and the whole family system. The group
will cover various topics including communication,trust, and tools to help the couple rebuild a
substance-free relationship.
• 4) Individual Counseling(average length of treatment,6 to 12 sessions): Primary client is seen on an
individual basis. Length of participation is dependent on client goals and progress toward goals.
5) Substance Abuse Therapy(average length of treatment, 12 to 20 sessions): A group to enhance
positive coping skills by focusing on their lifestyle dealing with use and abuse of chemicals.
6) Adult Intensive Outpatient(average length of treatment,4 to 12 weeks): An intensive outpatient
group therapy track that offers groups every evening,Monday through Friday,with a family program
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component. This program will include medical aspects of addiction and adult relapse education
components focusing on understanding the relapse process as well as group process(focuses on
individual issues relating to their abuse of alcohol). The program length and participation level will be
individualized based on the presenting issues and other factors.
7) Women's Group (average length of treatment, 12-20 sessions): A gender-specific group addressing
issues affecting women and their relationships, such as family violence,co-dependency,self-esteem and
stress management.
8) Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis
Users(MET/CBT5 average length of treatment 5-8 weeks): The MET/CBT5 is a brief treatment
approach for cannabis abusing adolescents. Treatment consists of two individual motivational
enhancement therapy sessions(MET)Sessions,followed by participation in three group cognitive
behavioral therapy (CBT)sessions. The assessment includes a psychosocial history and data
from the Global Assessment of Individual Needs(GAIN),and a personalized feedback report.
C. Special Program Option
1) Special Connections(through pregnancy and up to one year postpartum): A gender-specific
program that focuses on healthy babies,appropriate child care,prenatal care,birth control,
developmental stages of the baby,parenting skills,relationship issues, and other issues as identified by
the counselor. Services include group and individual therapy,case management and family health
education.
D. Miscellaneous Service Options
1) Fast Track Adolescent Program: The Fast Track Adolescent Program is an Intensive Outpatient
Program with supportive housing services if clinically necessary. The targeted population ranges from
13 to 17 years of age who demonstrate substance abuse problems. The goal is to have these adolescents
discover positive alternatives to their current use behavior. The program consists of a comprehensive
differential assessment compiling personal and collateral information as well as data obtained from the
Addiction Severity Index(ASI), Substance Abuse Subtle Screening Inventory(SASSI)and the
Adolescent Self-Assessment Profile(ASAP)instruments. This data is utilized to develop an
individualized treatment plan. Clients receive a minimum of three individual sessions with the focus on
achieving their treatment goals and attend three groups per week and three per day if in residential with
the primary focus on education and motivational topics. Family therapy is encouraged as a part of the
client's treatment. A discharge planning session will be implemented focusing on appropriate referrals
addressing the needs and motivation of the adolescent and family. To refer to the Fast Track Program,
Social Services will contact Program Manager of Youth Services at(970)356-6664,extension 16. If
she/he is not on duty, inform the staff person that Social Services is referring a Fast Track adolescent
and give the youth's caseworker's name so that the Fast Track staff can contact the caseworker when
they return to duty.
2) Extended Detoxify Stay: This is an option when case management goals require that the person be in
a stable environment until they can be referred to the next level of care.
3) Enhanced Services: Enhanced services as approved services that are requested by Social Services for
specific cases,which fall outside of the definitions,listed above in the description of the ADAD menu
of services. Enhanced services may be services not described on the menu,services not included in the
definition or due to lack of economy of scale,or rural location,or result in additional costs to Signal. In
order for Signal to provide enhanced service,the cost would be outside of the approved rates. Any
additional fees would be negotiated on a case-by-case basis.
Signal can arrange for services outside of the approved definitions,but Social Services will be charged
an additional fee that would be negotiated on a case-by-case basis by the designated representative
listed in the contract.
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E. Measurable Outcomes and Objectives
Signal shall abide by Social Services outcome indicators of Safety,Permanency and Child and Family Well-
Being,which are provided under Adoption and Safe Families Act (ASFA), 1997;
Colorado Child and Family Services Plan 2000-2004;and ACF Reviews(Reference: Federal Register,Volume
65,Number 16:45 CRF Parts 1355, 1356,and 1357),March 25,2000.
1) Outcome Reports as Prescribed by Social Services
Outcome reports will be developed and provided as mutually agreed upon by the
parties.
3) Client Objectives
The Social Services caseworker will identify a maximum of three child welfare objectives to be
addressed within each client's treatment plan. Signal shall develop action steps to reach the identified
child welfare objectives. Signal shall report monthly on each client's progress in meeting the three
identified objectives while the client is receiving treatment services
4) Overall Program Objectives
Signal and Social Services agree to monitor the ability of the substance abuse program offered by
Signal to achieve objectives as follows:
a) Demonstrate Abstinence with the use of UA/Patch Monitoring Only (Code#100).
b) Improve parental capabilities currently impaired by substance abuse(Code#101).
c) Develop the capacity to ask for help and assistance without resorting back to substance abuse
(Code#102).
d) Develop or increase the ability to recognize,prioritize and meet child(ren)'s needs(Code
#103).
e) Parent will identify how their substance use has affected their parenting(Code#104).
f) Parent will identify how their substance use got them involved with social services(Code
#105).
g) Parent will identify how their substance use helped them parent(Code#106).
h) Parent will identify relapse triggers and develop a safety plan for their children(Code#107).
i) Parent will identify whom they consider to be a support in their recovery(Code#108).
j) Parent will identify who will care for their children should they relapse(Code#109).
k) Parent will identify what they enjoy about parenting sober(Code#110).
1) Improve parent-child functioning to lower the risk of out of home placement(Code#201).
m) Parent will support their children in speaking about how living in a substance-effected family
has impacted them(Code#202).
n) Parents will demonstrate increased verbal skills,empathy and accountability with child(ren)
(Code#203).
o) Parent will identify their parenting strengths(Code#204).
p) Family members including significant other,children and extended family will increase ability
to communicate more effectively(Code#301).
q) Family members will identify how they can support the identified client in their recovery
(Code#302).
r) Family members will identify the positive parenting changes the substance-effected person is
making(Code#303).
s) Family members will identify who will care for the children in the event of a relapse(Code
#304).
t) Family members will identify relapse systems of the identified client(Code#305).
u) Family members will identify how they can reach out for help if a relapse occurs(Code#306).
v) Increase level of functioning currently impaired by living in a substance affected family(Code
#401).
w) Identify how living in substance effected family has impacted their life(Code#402).
x) Improve level of functioning currently impaired by substance abuse issues(Code#403).
y) Decrease aggressive behaviors at home and/or school and in the community(Code#404).
z) Learn how to socialize without the use of substances(Code#405).
aa) Identify relapse triggers(Code#406).
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bb) Create a sober support network(Code#407).
F. Staff Qualifications
Signal staff members who will provide services to Social Services clients will have credentials and/or
certifications as required by the Colorado Department of Human Services,Colorado Board of Education,
Alcohol and Drug Abuse Division,and the Colorado Board of Medical Examiners.
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EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to Signal in consideration for the work and services performed,a total
amount not to exceed Three Hundred Thousand Dollars($300,000.00)under Core Services Funding. Of this
total amount, Social Services agrees to pay an administrative fee not to exceed Fifteen Thousand($15,000.00) or
five percent of the service fees, salaries,and other authorized costs that are actually incurred in the delivery of
the treatment services authorized in this Agreement.
Payment pursuant to this Contract,if Colorado Core Services substance abuse treatment funding,whether in
whole or in part,is subject to and contingent upon the continuing availability of Colorado Core Services
substance abuse treatment funding for the purposes hereof. In the event that said funds, or any part thereof,
become unavailable as determined by Social Services,Social Services may immediately terminate this Contract
or amend it accordingly.
2. Fees for Services
Social Services agrees to pay for services according to Exhibit A,"Scope of Services",and according to the fees
described in Exhibit C,"Core Services Fee Schedule".
Social Services referrals will not be sent to collections by Signal for default of co-pay/fees. Services will be
performed regardless of client's refusal or inability to pay co-pay.
The Sliding Fee Schedule will only be applied to those services as noted in Exhibit C,"Core Services Fee
Schedule",all other fees will be charged directly to Social Services.
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EXHIBIT C
CORE SERVICES FEE SCHEDULE
1. General Core Services Fee Schedule
HIPAA Base Admin Payer
Service Code HIPAA Unit Rate Fee Rate
Antabuse Monitoring 110033 each $2.00 $0.10 $2.10
Antabuse Physical-Existing Client 99214 each $60.00 $3.00 $63.00
Antabuse Physical-New Client 99203 each $60.00 $3.00 $63.00
Breathalyzer 82075 each $2.00 $0.10 $2.10
Case Management 110006 15 minute session(s) N/A N/A N/A
Day Treatment: Adolescent H2012:HA hour(s) $9.87 $0.49 $10.36
Day Treatment: Adult H2012:HB hour(s) $6.90 $0.35 $7.25
Detox—OP I10012 day(s) N/A N/A N/A
Detoxification H0011 day(s) $185.00 $9.25 $194.25
Drug Patch Confirmation 110048 each N/A N/A N/A
Drug Patch Monitoring H0048:HF each $50.00 $2.50 $52.50
Evaluation H0002 15 minute session(s) $11.67 $0.58 $12.25
Evaluation: Rural H0002:TN 15 minute session(s) $16.67 $0.83 $17.50
Family Counseling/Couples Counseling T1006 15 minute session(s) $25.00 $1.25 $26.25
Group Counseling H0005 15 minute session(s) $6.75 $0.34 $7.09
Hair Testing 84999 each N/A N/A N/A
Individual Counseling H0004 15 minute session(s) $15.00 $0.75 $15.75
Intake T2010 each N/A N/A N/A
Intensive Short-Term Residential: H0018:HA day(s) $228.00 $11.40 $239.40
Adolescent
Intensive Short-Term Residential: Adult H0018:HB day(s) $170.00 $8.50 $178.50
Medical testimony 99075 15 minute session(s) $18.75 $0.94 $19.69
Multisystemic therapy for juveniles 112033 15 minute session(s) N/A N/A N/A
Opioid Replacement(Buprenorphine) J0592 month(s) N/A N/A N/A
Opioid Replacement(Methadone) 110020 month(s) $415.00 $20.75 $435.75
Prevention Information Dissemination 110024 15 minute session(s) N/A N/A N/A
Psychiatric Diagnostic Interview Exam 90801 15 minute session(s) N/A N/A N/A
Skills Training and Development H2014 15 minute session(s) N/A N/A N/A
Therapeutic Behavioral Srvc: Preg/Parent H2020:HD day(s) $99.50 $4.98 $104.48
Therapeutic Behavioral Srvcs: Adolescent H2020:HA day(s) $125.00 $6.25 $131.25
Therapeutic Behavioral Srvcs:Adult w/o H2020:HB day(s) $59.00 $2.95 $61.95
Infant
Transitional Long-Term Residential 110019 day(s) $93.00 $4.65 $97.65
Transitional Long-Term H0019:HD day(s) $175.00 $8.75 $183.75
Residential:Preg/Parent(NDF)
UA - 5 Panel 80101 each S12.00 ¶0.60 S 12.60
UA Confirmation 80102 each $35.00 $1.75 $36.75
UA-Dip Stick 81002 each N/A N/A N/A
UA-GC/MS -Quantitative 82542 per drug $18.00 $0.90 $18.90
UA-Oral Swab 82055 each $15.00 $0.75 $15.75
UA-Soma 81099 each N/A N/A N/A
UAw/TX H0003:HF each $12.00 $0.60 $12.60
Vapor inhalations evaluation 94664 each $40.00 $2.00 $42.00
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A GC/MS will automatically be completed without additional WCDSS authorization for all substances that test positive at
initial urine drug screening.
2. Special Core Services Fee Schedule
Assessments All assessments shall include documentation of at least two collateral contacts
to confirm/refute client self-reported information
Residential Youth residential services may be billed to core,as negotiated on a case-by-
case basis.
Adult Treatment Adult treatment,case management and after care(45-60 days).
Services
Ongoing Treatment Ongoing treatment services will be assigned to funding streams according to
usage,as negotiated on a case-by-case basis.
Youth Services Youth in Conflict(YIC)cases may be eligible for services through Core
Service dollars,as negotiated on a case-by-case basis.
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EXHIBIT D
ASSURANCES
1. Signal agrees it is an independent contractor and that its officers and employees do not become employees of
Weld County,nor are they entitled to any employee benefits as Weld County employees,as the result of the
execution of this Agreement.
2. Weld County,the Board of County Commissioners of Weld County,its officers and employees,shall not be held
liable for injuries or damages caused by any negligent acts or omissions of Signal or its employees,volunteers,
or agents while performing duties as described in this Agreement. Signal shall indemnify,defend,and hold
harmless Weld County,the Board of County Commissioners of Weld County, its employees,volunteers,and
agents. Signal shall provide adequate liability and worker's compensation insurance for all its employees,
volunteers,and agents engaged in the performance of the Agreement upon request, Signal shall provide Social
Services with the acceptable evidence that such coverage is in effect.
3. No portion of this Contract shall be deemed to constitute a waiver of any immunities the parties or their officers
or employees may possess,not shall any portion of this Agreement be deemed to have created a duty of care
with respect to any persons not a party of this Agreement.
4. No portion of this Contract shall be deemed to create an obligation on the part of the County of Weld,State of
Colorado,to expend funds not otherwise appropriated in each succeeding year.
5. If any section,subsections,paragraph,sentence,clause,or phrase of this Contract is for any reason held or
decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The parties
hereto declare that they would have entered into this Contract and each and every section,subsection,paragraph,
sentence,clause,and phrase thereof irrespective of the fact that any one or more sections, subsections,
paragraphs, sentences,clauses,or phrases might be declared to be unconstitutional or invalid.
6. No officer,member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof.
7. Signal assures that they will comply with the Title VI of the Civil Rights Act of 1986 and that no person shall,on
the grounds of race,creed,color,sex,or national origin,be excluded from participation in,be denied the benefits
of,or be otherwise subjected to discrimination under this approved Contract.
8. Signal assures that sufficient, auditable, and otherwise adequate records that will provide accurate,current,
separate,and complete disclosure of the status of the funds received under the Contract are maintained for three
(3)years or the completion and resolution of an audit. Such records shall be sufficient to allow authorized local,
Federal,and State auditors,and representatives to audit and monitor Signal.
9. All such records,documents,communications,and other materials shall be the property of Social Services and
shall be maintained by Signal, in a central location and custodian,in behalf of Social Services, for a period of
four(4)years from the date of final payment under this Contract,or for such further period as may be necessary
to resolve any matters which may be pending,or until an audit has been completed with the following
qualifications: If an audit by or on behalf of the federal and/or state government has begun but is not completed
at the end of the four(4)year period,or if audit findings have not been resolved after a four(4)year period,the
materials shall be retained until the resolution of the audit finding.
10. Signal assures that authorized local,federal,and state auditors and representatives shall,during business hours,
have access to inspect any copy records,and shall be allowed to monitor and review through on-site visits,all
contract activities,supported with funds under this Contract to ensure compliance with the terms of this
Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall
be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be
provided to the appropriate and interested parties.
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11. This Contract shall be binding upon the parties hereto,their successors,heirs,legal representatives,and assigns.
Signal or Social Services may not assign any of its rights nor obligations hereunder without the prior written
consent of both parties.
12. Signal certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of Signal,to
any person for influencing or attempting to influence an officer or employee of an agency, a Member of
Congress,an officer or employee of Congress,or an employee of a Member of Congress in connection with the
awarding of any Federal contract,the making of any federal grant,the making of any federal loan,the entering
into of any cooperative agreement,and the extension,continuation,renewal,amendment,or modification of any
Federal contract, loan,grant,or cooperative agreement.
13. Signal assures that it will fully comply with all other applicable federal and state laws. Signal understands that
the source of funds to be used under this Contract is: Colorado Core Services substance abuse treatment funds.
14. Signal assures and certifies that it and its principals:
A. Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transaction by a federal department of agency.
B. Have not,within a three-year period of preceding this Agreement,been convicted of,or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining,attempting to obtain,or performing a public(federal,state,or local)transaction or contract
under a public transaction;violation of federal or state antitrust statutes or commission of
embezzlement,theft,forgery,bribery,falsification or destruction of records,making false statements,or
receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(federal,state,or local)with commission of any of the offenses enumerated in paragraph 11(b)of this
certification;and
D. Have not within a three-year period preceding this Contract,had one or more public transactions
(federal,state,and local)terminated for cause or default.
15. The Appearance of Conflict of Interest applies to the relationship of Signal with Social Services when Signal
also maintains a relationship with a third party and the two relationships are in opposition. In order to create the
appearance of a conflict of interest,it is not necessary for Signal to gain from knowledge of these opposing
interests. It is only necessary that Signal know that the two relationships are in opposition. During the term of
the Contract, Signal shall not enter any third party relationship that gives the appearance of creating a conflict of
interest. Upon learning of an existing appearance of a conflict of interest situation, Signal shall submit to Social
Services,a full disclosure statement setting forth the details that create the appearance of a conflict of interest.
Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for Social
Services' termination, for cause,of its contract with Signal.
16. Signal shall protect the confidentiality of all applicant records and other materials that are maintained in
accordance with this Contract. Except for purposes directly connected to the administration of Child Protection,
no information about or obtained from any applicant/recipient in possession of Signal shall be disclosed in a
form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with Signal
written policies governing access to,duplication and dissemination of,all such information. Signal shall advise
its employees, agents,and sub-providers of Signal,if any,that they are subject to these confidentiality
requirements. Signal shall provide its employees,agents,and sub-providers of Signal, if any,with a copy or
written explanation of these confidentiality requirements before access to confidential data is permitted.
17. Proprietary information for the purposes of this contract is information relating to a party's research,
development,trade secrets,business affairs,internal operations and management procedures and those of its
customers,clients or affiliates,but does not include information(1)lawfully obtained from third parties,
(2)that which is in the public domain,or(3)that which is developed independently. Neither party shall use or
disclose directly or indirectly without prior written authorization any proprietary information concerning the
other party obtained as a result of this Contract. Any proprietary information removed from the State's site by
Signal in the course of providing services under this Contract will be accorded at least the same precautions as
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PY-0708-CORE-102
are employed by Signal for similar information in the course of its own business.
18. Signal certifies it will abide by Colorado Revised Statue(C.R.S.)26-6-104,requiring criminal background
record checks for all employees,contractors,and sub-contractors.
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•
PY-0708-CORE-102
EXHIBIT E
STANDARDS OF RESPONSIBILITY FOR CORE SERVICES
Signal and Social Services agree to develop a case management plan(aka substance abuse treatment plan)on
each referred family within 30 days of the date the Signal received the referral. The case management plan will
be monitored and modified monthly to measure progress toward goals. Copies of the case management plan
must be sent to the caseworker,program area supervisor,and Core and Service Contract Coordinator at Weld
County Department of Social Services,P. O.Box A,315 B N 11 Avenue,Greeley,Colorado 80632. The case
management plan will include,at a minimum,goals,timelines,and measurement of success.
2. Signal and Social Services agree to resolve level of care conflicts at the Signal/County level through cooperation.
Social Services and Signal shall attempt to resolve all levels of care conflicts and disputes at the lowest level
possible within each organization. Should Social Services and/or Signal fail to agree upon the level of care
offered by Signal,they may appeal the case directly to the County Director,or designee, and the Signal Chief
Operating Officer. Both Signal and Social Services will have an opportunity to provide consultation and
documentation regarding the appeal.Appeals are to be resolved within 72 working hours,unless good cause
justifies an extension.
3. Signal agrees that payments for levels of care are not authorized for reimbursement by Social Services until a
referral from Social Services is provided to Signal prior to services rendered by Signal.
4. Signal agrees not to accept any referral from Social Services unless the referral contains all information required
on the form and necessary for reimbursement by Social Services and authorized for reimbursement according to
Exhibit E,Item 20. If Signal accepts the referral without all data fields required on the referral form or
authorization, Signal may assume fiscal responsibility for the services provided under the incomplete referral.
Inaccurate information listed on the referral form by Social Services will be excluded as a fiscal responsibility
for Signal.
5. Signal agrees to provide access to all monthly client progress reports for clients with treatment charges by the 3`d
Wednesday after the month of service,via the Signal website. The monthly progress report for each client must
be entered into the Signal Service Management website by the provider previous to the monthly billing claims in
order for payment to be honored. Failure to submit such monthly reports will result in delays or forfeiture of
payment. It is expected,at a minimum, that these reports will reflect all information requested on Exhibit G,
Monthly Progress Report
6. Signal agrees to submit a final discharge summary of client outcomes to Social Services within thirty(30)
calendar days after the completion date.
7. Signal agrees to report expenditures and case disbursement at agreed upon times.
8. Signal agrees to assume fiscal responsibility for expenses incurred by Signal that do not meet the requirements of
Exhibit E of this Agreement.Those expenses incurred by Signal outside of the scope of Exhibit E requirements
are not eligible Social Services expenditures and shall not be reimbursed by Social Services.
9. Signal agrees to the definition of a complete and timely billing form for purposes of submitting an original bill
under Exhibit E, 8.A complete and timely billing form must include the following elements.
T
A. The billing must include all forms designed for Core Services reimbursement and approved by Social
Services;Core Services Authorization of Funds,Project Report,Update Report, and original signed client
verification forms for therapy and group services. Additionally,Signal agrees to provide Social Services
monitoring results(UA,BA,patch,tox trap swab)by faxing said results to Social Services at
970.346.7698 no later than 72 hours after the day of service.
C. The Department will determine billed services not eligible for payment by identifying conflicts in the
following:
1. Details provided in client referrals and renewals, including approved hours of service,begin and
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PY-0708-CORE-102
end dates of service,client name,and Case ID.
2. Details in supporting documentation provided by the Provider and submitted with the original
bill,including,but not limited to,original signed client verifications,receipt of monitoring
results,time of service and units or hours of service provided,and names of clients receiving the
services,and monthly progress reports with all the information specified on Exhibit G.
3. Details provided in the current approved contract and Notification of Financial Assistance,
including,but not limited to unit of service,cost per unit of service,and special conditions and/or
revisions to said contract.
The above items,9 C, 1,2,and 3,will supersede all requests from Signal for review of billing errors.
Items submitted for billing will be processed according to the criteria established by the above
documentation.
The Department will make obvious corrections to minor errors in the bill in order to expedite processing
the claims for payment. Minor errors include missing or transposed digits in Household Numbers,
TRAILS Case ID, or other Department-generated information.
D. An Administrative fee will be assessed to all fees reimbursed through County only funding. Such fees
include,but are not limited to,those service fees previously billed and determined by the Department to
be not eligible for payment.
10. Signal will develop and utilize evaluation tools(pre-and post-assessment test instruments)to collect necessary
data in cooperation with Social Services staff to monitor effectiveness of program.
11. Signal will meet with the Social Services designated supervisor quarterly and/or the Core Services Caseworker
(more if needed)to review program usage and effectiveness to discuss necessary improvements to better serve
families or increase referrals.
12. Signal will be available to meet with Social Services staff to explain program,time lines of response to referrals
and answer questions to enhance program.
13. Signal,or their authorized designee, will be available for the Families,Youth and Children(FYC)Commission
review and attendance at the FYC meetings.
14. Regarding all forms referenced herein in the Agreement, Signal shall replicate these forms in format,content and
according to the specifications of Social Services or as mutually agreed upon by Signal and Social Services.
Signal agrees to modify these treatment authorization forms according to Social Services specifications and
requirements.
15. Social Services will be responsible for electronically authorizing services to various Signal providers and
initially designating if Core funds shall be used for payment. Social Services shall assure that the authorization
will have all information required for reimbursement from the county.
16. Social Services agrees to provide Signal with the name of a primary contact who will be responsible for
interacting with Signal's data system.
17. Social Services agrees to provide TRAILS Remittance Advice and a Signal Remittance Summary(Exhibit G)to
Signal within five(5)business days of the monthly TRAILS Core Main Payroll date.
18. Social Services agrees to render payment for one full billing invoice at a time,as billed monthly by Signal,and
not to submit payment for a mixture of separate invoices within one payment.
Page 17 of 19
PY-0708-CORE-102
EXHIBIT F
SIGNAL BEHAVIORAL HEALTH NETWORK
QUALIFIED SERVICE ORGANIZATION AGREEMENT
Signal Behavioral Health Network(MSO)and Weld County Department of Social Services(Social Services)hereby enter
into a Qualified Service Organization Agreement whereby the MSO agrees to accept and serve Counties' clients
substance abuse treatment needs. In light of the relationship between County and the MSO, County requires client
identifying information and data and information related to the services furnished to the clients. County and MSO will
have this relationship from June 1,2007-June 30,2008,thus the QSOA will be in effect during this period of time.
Furthermore,the County:
1. Acknowledges that in receiving,storing,processing,or otherwise dealing with any information from
the MSO about the clients in the MSO's program,it is fully bound by the provisions of the federal regulations governing
Confidentiality of Alcohol and Drug Abuse Patient Records,42 CFR Part 2; and
2. Agrees to undertake in resisting judicial proceedings in any effort to obtain access to information
pertaining to clients otherwise than as expressly provided for in the federal confidentiality regulations,42 CFR Part 2.
Executed this day of ,2007.
jJillliam W.Wendt,CEO Ju Grieg , irector
Signal Behavioral Health Network W Co epartme t of Soci Services
V
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PY-0708-CORE-102
EXHIBIT G
MONTHLY PROGRESS REPORT FORMAT
Island Grove Regional Treatment Center, Inc.
[address]
Phone: Fax:
WELD COUNTY DSS AFS/CORE SERVICES MONTHLY REPORT FORM
To: DSS FAX: (970) 353-5215
(Caseworker's Name)
From: Telephone: (970) 313-
(Therapist's Name)
Date: Fax: (970)
Provider Name: Island Grove Regional Treatment Center Modality:
Client Name: HH#:
Month of: Year: Treatment Type:
Attitude: 1 2 3 4 5 (1 =very poor; 5=excellent)
Progress: 1 2 3 4 5
Participation: 1 2 3 4 5
Narration:
Groups Attended:
Date: Topic: Date: Topic:
Date: Topic: Date: Topic:
Date: Topic: Date: Topic:
Date: Topic: Date: Topic:
Date: Topic: Date: Topic:
Date: Topic: Date: Topic:
Date: Topic: Date: Topic:
Monitored Sobriety:
Date: Type/Result: Date: Type/Result:
Date: Type/Result: Date: Type/Result:
Date: Type/Result: Date: Type/Result:
Date: Type/Result: Date: Type/Result:
Date: Type/Result: Date: Type/Result:
Date: Type/Result: Date: Type/Result:
Date: Type/Result: Date: Type/Result:
Authorization for services valid: through ; requesting renewal? Yes
**Therapist affirms that the above information is true and correct:
(original signature)
Page 19 of 19
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