HomeMy WebLinkAbout20072660.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - NORTH RANGE BEHAVIORAL HEALTH
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 North Range
Behavioral Health, 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 North Range
Behavioral Health 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 22nd day of August, A.D., 2007, nunc pro tunc June 1, 2007.
-;77- BOARD OF COUNTY COMMISSIONERS
E OUNTY,
� COLORADO
ATTEST:
?� 4319 vid E. Long, Chair
Weld County Clerk to the B.; a►
^ , //,,n , � William H. J rke Pr -Tem
BY: A�' I (4 ft ': n.,I � �r_
De ty Cler o the Board C/ /
Willia . Garcia �A
AP AS ,
Robert . Masden
unty Attorney , ( ` vv�ar.
Douglas Rademac er
Date of signature: 6(07
2007-2660
SS0034
4
(Vet
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website: www.co.weld.co.us
ip Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
COLORADO MEMORANDUM
TO: David E. Long, Chair Date: August 20, 2006
Board of County Commissioners ry
FR: Judy A. Griego, Director, Social Services 1 Ci.
RE: Child Protection Agreement for Services bbstween the Weld County
Ty
Department of Social Services and North Range Behavioral Health
Enclosed for Board approval is a Child Protection Agreement for Services between the Weld
County Department of Social Services(Department) and North Range Behavioral Health(North
Range). This Agreement was reviewed at the Board's Work Session held on June 6, 2007.
The major provisions of the contract are as follows:
1. The term of the contract is June 1, 2007 through May 31, 2008.
2. The source of funding is Core Services funding.
3. North Range will provide physiological evaluations for parents involved in the child
welfare system.
4. The Department will reimburse North Range a maximum of$97,544 per year at rates
outlined in the Agreement.
If you have any questions, please telephone me at extension 6510.
2007-2660
Contract No.PY 07-08-CORE-88
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND NORTH RANGE BEHAVIORAL HEALTH
This Agreement,made and entered into the day of ,r 2007,by and between the Board of
Weld County Commissioners,on behalf of the Weld County Department of Social Services,hereinafter referred to
as"Social Services",and North Range Behavioral Health,hereinafter referred to as"Provider".
WITNESSETH
WHEREAS,required approval,clearance,and coordination have been accomplished from and with
appropriate agencies;and
WHEREAS,the Colorado Department of Social Services has provided specific Core Services resources to
Social Services for mental health services through the Community Mental Health Center; and
WHEREAS,Provider is the Community Mental Health Center for Weld County and is willing and able to
provide mental health services; and
WHEREAS, Social Services requires the services of a Community Mental Health Center to assist the
County to deliver psychological evaluation and assessment services for child welfare families,children,and
adolescents; and.
WHEREAS, Social Services desires to enter into an agreement with Provider to benefit the positive
development of treatment plans,placement options,and timely reunification of families through quality and cost
effective mental health evaluations.
NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as follows:
1. Tenn
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
Services shall be provided by Provider to any person(s)eligible for child welfare 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,"a copy of which is
attached and incorporated by reference."Payment Schedule"shall establish the maximum
reimbursement,which will be paid from Colorado Family Preservation Act funds during the
duration of this Agreement.
b. Provider shall submit an itemized monthly bill to Social Services for all costs incurred and
services provided pursuant to Exhibit A,"Scope of Services"of this Agreement in accordance
with criteria established by Social Services. The Provider shall submit all itemized monthly
billings to Social Services no later than the twenty-fifth(25)day of the month following the month
the cost was incurred.
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Contract No. PY 07-08-CORE-88
Failure to submit monthly billings in accordance with the terms of this agreement shall result in
Provider forfeiture of all rights to be reimbursed for such expenses. In the event of a
forfeiture of reimbursement,Provider may appeal such circumstance to the Director of Social
Services. The decision of the Director of Social Services shall be final.
c. Payments of costs incurred pursuant to this Agreement are expressly contingent upon the
availability of Colorado Family Preservation Act funds to Social Services.
d. 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." Work performed prior to the
execution of this Contract shall not be reimbursed or considered part of this Agreement.
4. Financial Management
At all times from the effective date of this Contract until completion of this Contract,Provider 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 Colorado Family Preservation Act must conform to the Single Audit Act of 1984 and OMB
Circular A-128.
5. Payment of Method
Unless otherwise provided in the Scope of Services and Payment Schedule:
a. Provider shall provide proper monthly invoices and verification of services performed for costs
incurred in the performance of the agreement.
b. Social Services may withhold any payment if Provider has failed to comply with the Financial
Management Requirements,program objectives,contractual terms,or reporting requirements. In
the event of a forfeiture of reimbursement,Provider may appeal such circumstance to the Director
of Social Services. The decision of the Director of Social Services shall be final.
6. Assurances
Provider shall abide by all assurances as set forth in the attached Exhibit C,"Assurances"which is attached
hereto and incorporated herein by reference.
7. Compliance with Applicable Laws
At all times during the performance of this contract,Provider 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 this Contract. Provider acknowledges that the following laws are included:
Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-1 et. Seq.and its implementing
regulation,45 C.F.R. Part 80 et. Seq.; and
Section 504 of the Rehabilitation Act of 1973,29 U.S.C. Section 794,and its implementing
regulation,45 C.F.R.Part 84;and
the Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et seq. and its implementation
regulation,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
- Immigration Reform and Control Act of 1986,P.L. 99-603;
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Contract No.PY 07-08-CORE-88
and 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.
Included if 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 Social Services or with the U.S. Department of Health and Human Services,
Office for Civil Rights.
8. Certifications
Provider 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
Provider and Social Services agree that monitoring and evaluation of the performance of this Agreement
shall be conducted by Provider and Social Services. The results of the monitoring and evaluation shall be
provided to the Board of Weld County Commissioners and the North Range Behavioral Health Board.
Provider shall permit Social Services,and any other duly authorized agent or governmental agency,to
monitor all activities conducted by the Provider pursuant to the terms of this Agreement. As the
monitoring agency may in its sole discretion deem necessary or appropriate,such program date,special
analyses,on-site checking, formal audit examinations,or any other reasonable procedures. All such
monitoring shall be performed in a manner that will not unduly interfere with agreement work.
10. Modification of Agreement
All modifications to this agreement shall be in writing and signed by both parties.
11. Remedies
The Director of Social Services or designee may exercise the following remedial actions should s/he find
Provider 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 Provider.
These remedial actions are as follows:
a. Withhold payment to Provider until the necessary services or corrections in performance are
satisfactorily completed;
b. Deny payment or recover reimbursement for those services or deliverables which have not been
performed and which due to circumstances caused by Provider 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;
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Contract No. PY 07-08-CORE-88
c. Incorrect payment to Provider due to omission,error,fraud,and/or defalcation shall be recovered
from Provider by deduction from subsequent payments under this Agreement or other agreements
between Social Services and Provider,or by Social Services as a debt due to Social Services or
otherwise as provided by law.
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 Title
For North Range Behavioral Health:
Wayne Maxwell, Executive Director,North Range Behavioral Health
Name Title
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: North Range Behavioral Health
Judy A. Griego,Director Wayne Maxwell,Executive Director
P.O.Box A 1306 11th Avenue
Greeley,CO 80631 Greeley,CO 80631
14. Litigation
Provider shall promptly notify Social Services in the event that Provider learns of any actual litigation in
which it is a party defendant in a case,which involves services provided under this Agreement. Provider,
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 funding.
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.
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Contract No. PY 07-08-CORE-88
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first
above written.
ATTEST:
ace
D COUNTY BOARD OF COUNTY
t ` 47 x MISSIONERS
CLERK TO THE BOARD y , ti'�� u C• 1 TY, OLO O
B
;;~v! David E.Long,Chair
By: a ut erk an /22/2007
P Y
APPI;rE7VED
..o �
/ unt�rney
WELD COUNTY DEPARTMENT NORTH RANGE BEHAVIORAL HEALTH
OF SOCIAL SERVICES
By: / By: (/' , /L R._ --11-244C-Attued
Judy . Grieg ,Director Wayne Maxwell,Executive
By:
Board Chairperson
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&cc7- O76 H
Contract No.PY 07-08-CORE-88
EXHIBIT A
SCOPE OF SERVICES
1. Target/Eligible Population
Social Services will refer child welfare family members who are non-Medicaid eligible abused and
neglected children who are at risk of out-of-home placement or who are clients of Social Services and are
in need of Provider services.The family members of these children and adolescents will also be eligible for
services.
2. Types of Services to be Provided
Services to be provided under the terms of this contract by Provider will be provided,at a minimum,
by an academically qualified,post doctorate candidate for licensure under the constant direct
supervision of a licensed clinical psychologist,and shall include the following:
All services will be referred via email by the Core Services Caseworker. The referral authorization level
will be clearly stated on the referral. Any supporting documentation available via email will be sent with
the referral. Otherwise,the assigned Clinician can contact the Child Protection Caseworker for additional
documentation.
The initial referral will be for either: a Mental Health Evaluation;a Partial Psychological Evaluation;or a
Full Psychological Evaluation. If the caseworker wishes to refer for a Mental Health Evaluation,and
authorize a full evaluation if necessary,a notation approving this will be provided in the"narrative"
section. Otherwise,prior to Provider continuing with a full evaluation,a one-page summary of the reasons
why this recommendation is being made must be emailed to the Core Services Caseworker,and
authorization to continue from the Core Services caseworker received in return. The Core Services
caseworker will consult with the Child Protection caseworker and/or their supervisor regarding
authorization.
Referrals contain start and end dates for payment authorization. Only services provided within those
authorization dates will be paid by the Department. Any services provided outside those dates will be
denied for payment.
Regular Core Service billing procedures must be followed,for payment to be processed. Billing for the
prior month's services is due at the Department at the latest the 25th day of the current month. The original
report must be attached to the billing for payment to be processed. Client Verifications,without original
client signatures,must also be attached to the billing and report. See attached billing documents below.
3. Service and Pilot Objectives
Provider evaluations will prove beneficial to clients of Social Services by Provider's identification and
documentation of appropriate treatment recommendations through its evaluation and Social Services'
incorporation of such treatment recommendations in Social Services treatment plans,as adopted by the
Court.
4. Service Time Frames
a. Evaluations,through a written report,will be completed within forty-five(45)days from the point
of a face to face pre-referral staffing of the evaluation between Provider and Social Services,
provided that the client can be reached for appointments and the client attends appointments as
scheduled.
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b. Deadlines will be extended by Social Services on behalf of Provider when clients cannot be found
or reached.
c. If a client partially complies with appointments,Provider will write the evaluation based on
information obtained up to that date and prorated based on hours performed by Provider. If no
appointments have been made,the evaluation referral may be dropped by Provider due to the
client's failure to follow through and Provider will not bill Social Services.
5. Measurable Outcomes
Provider and Social Services wish to evaluate the quality and cost effectiveness of evaluations by
conducting two surveys of Provider evaluation staff and Social Services caseworkers during the term of the
Agreement and as identified by Provider and Social Services. The content of the survey will be agreed
upon by both parties.
6. Workload Standards
Provider will complete five(5)to ten(10)evaluations per month,depending on the level of evaluations
referred by Social Services.
7. Staff Qualifications
The Provider staff performing the evaluations will be a licensed or licensed eligible psychologist with
appropriate training and expertise with formal evaluation techniques.
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EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
The total funding available under this agreement is Ninety Seven Thousand Five Hundred Forty-Four
dollars($97,544.00),as follows:
Social Services agrees to reimburse to Provider in consideration for the work and services performed for a
total not to exceed Ninety Seven Thousand Five Hundred Forty-Four dollars($97,544.00).
Expenses incurred by Provider,in association with said project prior to the term of this agreement,are not
eligible Social Services expenditures and shall not be reimbursed by Social Services.
Payment pursuant to this Contract,whether in whole or in part,is subject to and contingent upon the
continuing availability of Core Services Funds 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
Three-Tier Flat Rate Psychological Evaluation Options
Level 1: Mental Health Evaluation
Cost: $200.00
Est.Time: 3-6 hours
Example:
1. Review of DSS case records,and if applicable NRBH records.
2. Clinical interview and diagnostic evaluation.
3. Possible administration of brief screening inventories (e.g., Beck Inventories, State-Trait
Inventories,Personality Assessment Screener).
4. Feedback given to the client.
5. Written report addressing relevant psychosocial history, diagnostic formulation, and
treatment recommendations.
The Mental Health Evaluation can be useful for ruling in/out basic mental health issues, advising
on provisional diagnoses,and making recommendations for treatment when appropriate.
Level 2: Partial Psychological Evaluation
Cost: $800.00
Est.Time: 8-14 hours
Example:
1. Review of DSS case records,and if applicable NRBH records.
2. Clinical interview and diagnostic evaluation.
3. Administration of a partial test battery (e.g., administration of just a couple of formal
tests,or administration of just cognitive or just personality testing).
4. Consultation with collateral sources.
5. Feedback given to the client.
6. Write-up addressing psychosocial history, test results, diagnostic formulation, and
treatment recommendations.
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This evaluation can be useful for ruling in/out mental health and/or personality issues,advising on
diagnoses,and making treatment recommendations.
Level 3: Full Psychological Evaluation
Cost: $1200.00
Est.Time: 16-20 hours
Example:
1. Review of all available records, including DSS records, prior evaluation and mental
health treatment records, NRBH records if applicable, police reports, medical records,
and records from other agencies involved in the case.
2. Extensive clinical evaluation(multiple sessions).
3. Administration of a formal battery of tests (multiple tests) to assess personality,
emotional,and cognitive functioning,and/or parenting issues.
4. Consultation with collateral sources.
5. Feedback given to the client.
6. Write-up addressing psychosocial history, personality issues, emotional functioning and
regulation abilities, intellectual functioning and/or parenting/family issues, and diagnostic
formulation,as well as treatment recommendations and prognosis.
This evaluation can be useful in identifying more significant mental health issues and diagnoses,
as well as addressing personality issues, intellectual functioning, the ability to manage emotions,
parenting issues and potential safety of the children in the home, placement issues, and treatment
recommendations.
Over the term of this Agreement Provider will include 40 hours of court testimony including
preparation of and actual testimony without additional charge. Court testimony in excess of 40
hours will be billed separately at a rate of$110.00 per hour.
a. Provider agrees to:
1) Attach copies of the completed evaluation at the time of billing to the Core and
Service Contract Coordinator at Weld County Department of Social Services,P.
O.Box A,315 B N. 11th Avenue,Greeley,Colorado,80632.
2) A complete and timely billing form is identified by and must include the
following elements.
a) The billing must be an original billing signed by the provider and/or
designee.
b) Evaluations must include the client's full name,Weld County
household number,beginning and ending date of the referral,client
verification forms with original client signatures,hours performed,and
total billed for the evaluation.
c) Requests for payment must be an original and submitted to the Weld
County Department of Social Services by the end of the 25th calendar
day following the end of the service.The provider must submit requests
for payment on forms,as approved by the Social Services.
d) The number of hours for preparation of and actual court testimony
provided by Provider.
3) Participate in staffings and/or Core Review Team as requested or necessary.
Participate in the quarterly feedback process at Weld County Social Services.
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4) Be available to meet with Social Services staff to explain program,time lines of
response to referrals and answer questions to enhance program.
5) Be available for the Families,Youth and Children Commission review and
attendance of the FYC meeting,if requested.
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EXHIBIT C
ASSURANCES
1. Provider agrees it is an independent Provider 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 Provider or its
employees,volunteers,or agents while performing duties as described in this Agreement. Provider 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,Provider 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,nor shall any portion of this Agreement be deemed to have treated a
duty of care with respect to any persons not a party to 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. Provider assures that they will comply with the Title VI of the Civil Rights Act of 1964 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. Provider 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 of 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 Provider.
9. All such records,documents,communications,and other materials shall be the property of Social Services
and shall be maintained by Provider,in a central location and custodian, in behalf of Social Services, for a
period of three(3)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 qualification: 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 three(3)year period,or if audit findings have not been resolved after a
three(3)year period, the materials shall be retained until the resolution of the audit finding.
10. Provider 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. Provider or Social Services may not assign any of its rights or obligations hereunder without the
prior written consent of both parties.
12. Provider certifies that Federal appropriated funds have not been paid or will be paid,by or on behalf of
Provider,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. Provider assures that it will fully comply with the Children's Code regulations promulgated,and all other
applicable federal and state laws,rules and regulations. Provider understands that the source of funds to be
used under this Contract is: Family Issues Cash Funds.
14. Provider assures and certifies that it and its principals:
a. Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transactions 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 of default.
15. The Appearance of Conflict of Interest applies to the relationship of a Provider with Social Services when
Provider also maintains a relationship with a third party and the two relationships are in opposition. In
order to create the appearance of a conflict of interest,it is not necessary for the Provider to gain from
knowledge of these opposing interests. It is only necessary that the Provider know that the two
relationships are in opposition.
During the term of the Contract Provider 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,Provider 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 Provider.
16. Provider shall protect the confidentiality of all applicant records and other materials that are maintained in
accordance with this Contract. Except for purposes directly connected the administration of the Child
Protection,no information about or obtained from any applicant/recipient in possession of Provider shall be
disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian. Provider shall
have written policies governing access to,duplication and dissemination of,all such information. Provider
shall advise its employees,agents,and subProviders,if any,with a copy or written explanation of these
confidentiality requirements before access to confidential data is permitted.
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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 Provider in the course of providing services under this Contract will be
accorded at least the same precautions as are employed by Provider for similar information in the course of
its own business.
18. Provider agrees to provide a written certification to Social Services of its compliance with Section 26-6-
104(7),C.R.S,regarding background checks with current and prospective employees,Providers and
subProviders whose employees have direct contact with children.
19. Provider certifies that it shall comply with the provisions of Colorado Revised Statutes(C.R.S.) 8-17.5-101,
et seq. Provider shall not knowingly employ or contract with an illegal alien to perform work under this
Contract or enter into a contract with a subProvider that fails to certify to Provider that the subProvider
shall not knowingly employ or contract with an illegal alien to perform work under this Contract. Provider
represents, warrants, and agrees that it (a) has verified that it does not employ any illegal aliens, through
participation in the Basic Pilot Employment Verification Program administered by the Social Security
Administration and Department of Homeland Security, and (b) otherwise will comply with the
requirements of C.R.S. 8-17.5-102(2)(b). Provider shall comply with all reasonable requests made in the
course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment.
If Provider fails to comply with any requirement of this provision or C.R.S. 8-17.5-101, et seq., Social
Services may terminate this Contract for breach and Provider shall be liable for actual and consequential
damages to Social Services.
Except where exempted by federal law and except as provided in C.R.S. 24-76.5-103(3), if Provider
receives federal or state funds under this Contract,Provider must confirm that any individual natural person
eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. 24-76.5-
103(4) if such individual applies for public benefits provided under this Contract. If Provider operates as a
sole proprietor, it hereby swears or affirms under penalty of perjury that it (a) is a citizen of the United
States or is otherwise lawfully present in the United States pursuant to federal law,(b) shall produce one of
the forms of identification required by C.R.S. 24-76.5-101, et seq., and (c) shall produce one of the forms
of identification required by C.R.S. 24-76.5-103 prior to the effective date of this Contract.
Page 13 of 14
Contract No.PY 07-08-CORE-88
EXHIBIT D
BILLING PROCEDURES
1. All billings are to be submitted by the 10`he day of the month following the month of
service. If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
2. Billings must be submitted with the attached required forms, Authorization for
Contractual Services, Request for Reimbursement and Client Verification Form. The
forms must be submitted with original signatures.
3. For monitored sobriety, proof of services rendered shall be a sign-in sheet with client
signatures or the test result.
Page 14 of 14
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
Program Year 2007-08
TO BE COMPLETED BY PROVIDER:
Date:
Provider: Billing Contact:
Phone Number:
Address:
Description of Services:
Service Month / Year: Charges: $
I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE
INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE
CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF SOCIAL
SERVICES.
Printed Name of Signer Provider Signature Date
(Original signature REQUIRED—NO FAXES)
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
FOR COUNTY USE ONLY:
AMOUNT AUTHORIZED FOR PAYMENT: $
Approvals:
/
Core & Service Contract Coordinator Date
Director Date
Comments:
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