HomeMy WebLinkAbout20052406.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - GRIFFIN HOUSE
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 Griffin House,
commencing June 1, 2005, and ending May 31, 2006, 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 Griffin House
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 15th day of August, A.D., 2005, nunc pro tunc June 1, 2005.
BOARD OF COUNTY COMMISSIONERS
"3_�f'% WELD COUNTY, COLORADO
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Robert D. MasdeenaelA
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Date of signature: er
2005-2406
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DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO
MEMORANDUM
TO: William H. Jerke, Chair Date: August 5, 2005 _
Board of County Commissioners t
FR: Judy A. Griego, Director, Social Services ,.71.1.(1'
RE: Child Protection Agreement for Services between the Weld County
Department of Social Services and Griffin House.
Enclosed for Board approval is a Child Protection Agreement for Core Services between the
Weld County Department of Social Services (Department)and Griffin House.
The major provisions of the contract are as follows:
1. The term of the contract is June 1, 2005 through May 31, 2006.
2. The source of funding is Core Services funding.
3. Griffin House will provide monitored sobriety services and treatment for adolescents
involved in the child welfare system.
4. The Department will reimburse Griffin House an amount not to exceed$50,000 and
according to their fee schedule.
If you have any questions,please telephone me at extension 6510.
2005-2406
Contract Number 05 CORE-51
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND GRIFFIN HOUSE
This Agreement,made and entered into the ''day of May 2005,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 Griffin House, hereinafter referred to as"Griffin House."
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 Core Service funding to Social Services
for immediate referrals for monitored sobriety services for families, children, and adolescents;and
WHEREAS, Social Services requires the services of a substance abuse treatment provider to assist the County to
deliver services for immediate referrals for monitored sobriety to child welfare clients,and Griffin House is willing and
able to provide such services; and
WHEREAS, Social Services requires the services of a substance abuse treatment provider to assist Social
Services in delivering substance abuse treatment services to child welfare clients upon the depletion of Core funding;and
WHEREAS,Griffin House 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 1,2005,upon proper execution of this Agreement and shall
expire May 31, 2006,unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by Griffin House network providers 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,"copies of which are attached
hereto and incorporated herein by reference.
"Payment Schedule"shall establish the maximum reimbursement,which will be paid from Core Service
funds during the duration of this Agreement.
Griffin House, in accordance with federal HIPAA regulations,will be adopting the standard transaction
code set for all treatment services on or before October 16,2003. Even though this
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Contract Number 05 CORE-51
compliance will change the service labels and groupings,the net fees associated with those services will
not change.
b. Griffin House 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. Griffin House 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.
c. Payments of costs incurred pursuant to this Agreement is expressly contingent upon the availability of
Core Service 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. 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, Griffin House 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
Core Service 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. Griffin House shall provide proper monthly invoices and itemization of services performed for costs
incurred in the performance of the agreement.
b. Social Services may withhold any payment if Griffin House has failed to comply with the Financial
Management Requirements,program objectives, contractual terms,or reporting requirements. In the
event of a forfeiture of reimbursements, Griffin House may appeal such circumstance to the Director of
Social Services. The decision of the Director of Social Services shall be final.
6. Assurances
Griffin House shall abide by all assurances as set forth in the attached Exhibit C,which is attached hereto and
incorporated herein by reference.
7. Compliance with Applicable I aws
At all times during the performance of this contract, Griffin House 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. Griffin
House 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 regulations,45
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Contract Number 05 CORE-5I
C.F.R.Part 84;and
the Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et seq.and
its implementation regulations,45 C.F.R.Part 91;and
Title VII of the Civil Rights Act of 1964;and
- the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
- the Education Amendments of 1972;and
- Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
and all regulations applicable to these laws prohibiting discrimination because of race,color,national
origin,and sex,religion and handicap, including 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, Griffin House and Social Services will resist in judicial proceedings any efforts to obtain access to
client records except as permitted by 42 CFR Part 2.
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
Griffin House 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
Griffm House and Social Services agree that monitoring and evaluation of the performance of this Agreement
shall be conducted by Griffm House and Social Services. The results of the monitoring and evaluation shall be
provided to the Board of Weld County Commissioners and Griffm House.
Griffin House shall permit Social Services, and any other duly authorized agent or governmental agency,to
monitor all activities conducted by Griffin House pursuant to the terms of this Agreement. As the monitoring
agency may in its sole discretion deem necessary or appropriate,such program data, special analyses, on-site
checking, formal audit examinations,or any other reasonable procedures. All such monitoring shall be
performed in a manner that will not unduly interfere with 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 Griffin
House 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 Griffin House. These
remedial actions are as follows:
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Contract Number 05 CORE-51
a. Withhold payment to Griffin House 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 Griffin House cannot be performed or if
performed would be of no value to Social Services. Denial of the amount of payment shall be
reasonably related to the amount of work or deliverables lost to Social Services;
c. Incorrect payment to Griffin House due to omission,error,fraud,and/or defalcation shall be recovered
from Griffin House by deduction from subsequent payments under this Agreement or other agreements
between Social Services and Griffin House,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 Serial Services Administrator
Name Title
For Griffin House:
James P Nelson Executive Director,Griffin House
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: Griffin House
Judy A Griego,Director Tames P Nelson,Executive Director
P O Box A 160011 St Avenue
Greeley,CO 80619 Greeley,CO 50611
14. l.itiution
Griffin House hall promptly notify Social Services in the event that Griffin House learns of any actual litigation
in which it is a party defendant in a case that involves services provided under this Agreement. Griffin House,
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. Griffin House reserves the right to suspend services to clients if funding is no longer
available.
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Contract Number 05 CORE-51
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 above
/1/M
BOARD OF COUNTY
O OARD COMMISSIONERS WELD
- COUNTY,COLORADO
0 .fir{
By.• (1 I X spry*ty Clerk William H.Jerke,Chair 5
AUG 1 2005
AI?PR D AS TO F GRIFFIN HOUS
BY
County ttomey J es P.Nelson,Executive Director
WELD COUNTY DEPARTMENT
OF SOCIAL S RVICES
By:
Ju rie o,Direc
•
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O?GOs-ayo6
Contract Number 05 CORE-51
EXHIBIT A
SCOPE OF SERVICES
1. Overall Project Description
Griffin House shall provide services including client evaluations, substance abuse treatment, sobriety monitoring,
case consultation and testimony in court for adolescents referred by Social Services. Each client's treatment
needs will be assessed on an individual basis,and the level or modality of treatment provided by Griffin House
will be based on the client's needs, in accordance with the American Society of Addiction Medicine's(ASAM)
patient placement criteria.
2. Eligible Population for Services
Social Services will refer to Griffin House youth ages twelve to nineteen and who have an open child welfare
case or at imminent risk of out of home placement due to their substance abuse.
3. Types of Services To Be Provided
A. Adolescent Substance Abuse Assessment
Griffin House will evaluate and assess alcohol/drug involvement as well as mental health status, sexual
history, legal history and administer certain standard tests(ASAP, SASI,ASAM, Walmyr Scales).
Griffin House will provide a summary of assessment including recommendations to the Social Services'
case manager. Griffin House's substance abuse evaluator will complete the assessment within 10
working days of the face-to-face interview.
Griffin House agrees to include a Baseline Urinalysis Testing(7-Panel)as part of the assessment.
B. Treatment Options
Griffin House's treatment options will be dependent upon the American Society of Addiction Medicine
(ASAM)level of care that is formulated at the completion of the substance abuse assessment. Through
group,family, and individual counseling,the methods used to create change are generated through
cognitive and behavioral therapy, Gestalt,problem solving techniques,motivation enhancement,and
solution focused therapy. These will be used in conjunction with or alone depending upon the client's
needs. Griffin House agrees to provide the ASAM level of care as follows:
Level of Care Description
• .5= 10 Groups Client meets once a week for 90 minutes, family therapy for
one hour a week, and one individual counseling session per
month.
1.0=20 Groups Client meets once a week for 90 minutes; family therapy
one hour a week, and two individual sessions per month.
Over 1.0=30 groups Client meets once a week for 90 minutes; family therapy
one hour a week, and up to four individual sessions per
month.
C. Reporting
Griffin House will provide monthly reports to Social Services concerning the status of each participant
including both monthly aggregate and client progress reports. All client progress reports submitted by
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Contract Number 05 CORE-51
Griffin House will be substantive, clearly written, and signed by the clinician,therapist, or evaluator.
Griffin House will utilize the monthly progress report form created by Social Services. Griffin House
will incorporate into each youth treatment plan the child welfare objective as identified by the Social
Services caseworker. These objectives are derived from the Social Services' caseworker's assessment
and state what must be done to undertake behavioral changes, to mitigate safety concerns,to resolve
risks and to result in family continuity and/or permanency. These reports will be provided to Social
Services by the twenty-fifth day of each month.
4. Fee Schedule for Services
Griffin House's fee schedule for services is as follows:
Description of Services Fee/Cost
Drug and Alcohol Assessments,which includes $35.00 Per Hour (Maximum of 6 Hours)
SASI,ASAP,ASAM&Walmyr Scales
UA with Assessment including random UAs for 3 Panel UA-$10.00
2-3 times per week 3 Panel Confirmation-$10.00
5 Panel UA- $15.00
5 Panel Confirmation-$15.00
7 Panel UA-$20.00
7 Panel Confirmation-$20.00
Drug/Alcohol Treatment Counseling Groups $45.00 Per Person Per Group for 90 minutes
Individual Counseling $20.00/hr Supervised CACII
$45.00/hr LPC/LCSW
Family Therapy $45.00/hr LMFT
5. Measurable Outcomes and Objectives
Griffin House 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.
a. Client Objectives
The Social Services caseworker will identify three child welfare objectives to be addressed within each
client's treatment plan. Griffin House shall develop action steps to reach the identified child welfare
objectives. Griffin House shall report monthly on each client's progress in meeting the three identified
objectives. Each objective will be measured via a percentage Likert Scale to determine progress.
b. Overall Program Objectives
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Contract Number 05 CORE-51
Griffin House and Social Services agree to monitor the ability of the substance abuse program offered
by Griffin House to achieve objectives as follows:
1) Increase level of functioning currently impaired by substance abuse.
2) Decrease in aggressive behaviors at home and/or school and in the community.
3) Develop the capacity to ask for help and assistance with out resorting back to substance abuse.
4) Youth will demonstrate increased verbal skills, empathy and accountability
5) Youth will develop problem-solving skills when confronted with a relapse trigger
6) Youth will address past/current victimization issues that interfere with their ability to maintain
sobriety.
7) Improve Parent-child functioning to lower the risk of out of home placement
8) Family member will identify and implement opportunities to support the youth in their
recovery.
6. Workload Standards
Griffin House will meet the following,workload standards:
a. Complete up to eight youth substance abuse evaluations per month;
b. Begin group treatment with a minimum of four clients not to exceed 12 clients per group. Should there
not be enough clients to begin a group,Griffin House will work with the youth on an individual basis
until they can be transitioned to a group.
7. Staff Qualifications
Griffin House staff members who will provide services to Social Services will have credentials and/or
certifications as required by the Colorado Department of Human Services,Alcohol and Drug Abuse Division.
a. CACII; A CACII level counselor will be utilized when it appears that the primary issue is substance
abuse with underlying home/social factors.
b. LPC/LCSW; A LPC/LCSW will be utilized when the clients' substance abuse issues are a direct result
of home/social factors.
c. Case Manager; A Griffin House case manager will be assigned to every Social Services client that is
referred for substance abuse services.
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Contract Number 05 CORE-51
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to Griffin House in consideration for the work and services performed, a total
amount not to exceed Fifty Thousand dollars($50,000.00)under Core Service funding.
Expenses incurred by Griffin House, 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,if Core Service funds,whether in whole or in part, is subject to and contingent
upon the continuing availability of Core Service 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
Fees for services will be based on services and fees as described in Exhibit A.
Social Services referrals will not be sent to collections by Griffin House 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 on the fee schedule,all other fees will
be charged directly to Social Services.
Griffin House will collect any applicable sliding scale co-pays and credit Social Services for any payments
received on the monthly billing statements.
For those clients who have the responsibility to pay for their own treatment and related services as documented
by court order, Griffin House will treat such clients as a non-Social Services referral and according to its rules
and regulations afforded to other community clients.
3. Submittal of Vouchers
Griffin House shall prepare and submit monthly the itemized voucher according to the criteria listed under
"Standards of Responsibility" in Exhibit D,and certify that the services authorized were provided on the date
indicated and the charges made were pursuant to the terms and conditions of Exhibit A.
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Contract Number 05 CORE-51
EXHIBIT C
ASSURANCES
1. Griffin House 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 Griffm House-contracted providers or
its employees, volunteers, or agents while performing duties as described in this Agreement. Griffin House shall
indemnify,defend,and hold harmless Weld County,the Board of County Commissioners of Weld County, its
employees,volunteers,and agents. Griffin House 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,Griffin House 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 treated 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. Griffin House 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. Griffin House 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 Griffin House.
9. All such records,documents,communications, and other materials shall be the property of Social Services and
shall be maintained by Griffin House,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. Griffm House 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,
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Contract Number 05 CORE-51
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.
11. This Contract shall be binding upon the parties hereto,their successors, heirs, legal representatives,and assigns.
Griffin House or Social Services may not assign any of its rights or obligations hereunder without the prior
written consent of both parties.
12. Griffin House certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of
Griffin House,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. Griffin House assures that it will fully comply with all other applicable federal and state laws. Griffin House
understands that the source of funds to be used under this Contract is Core Service funds.
14. Griffin House 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 a contractor with Social Services when the
contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to
create the appearance of a conflict of interest, it is not necessary for the contractor to gain from knowledge of
these opposing interests. It is only necessary that the contractor know that the two relationships are in opposition.
During the term of the Contract,Griffin House 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, Griffin House 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 Griffin House.
16. Griffin House shall protect the confidentiality of all applicant records and other materials that are maintained in
accordance with this Contract. Except for purposes directly connected with the administration of Child
Protection,no information about or obtained from any applicant/recipient in possession of Griffin House shall
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Contract Number 05 CORE-51
be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in
accordance with Griffin House written policies governing access to, duplication and dissemination of,all such
information. Griffin House shall advise its employees, agents,and subcontractor, if any,that they are subject to
these confidentiality requirements. Griffin House shall provide its employees,agents, and subcontractors,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 Griffin House
in the course of providing services under this Contract will be accorded at least the same precautions as are
employed by Griffin House for similar information in the course of its own business.
18. The Contractor 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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Contract Number 05 CORE-51
EXHIBIT D
CORE SERVICE FUNDS
Standards of Responsibility
Griffin House agrees to:
1. Provide a written report to the Social Services caseworker within 24 hours of providing services to the client;
2. Report to Social Services a monthly brief report on the status of the program as prescribed by Social Services;
3. Report expenditures and case disbursement at agreed upon times.
4. Submit monthly-completed billing forms to Ms. Elaine Furister,CPS/CAP, Core Services Specialist,within
twenty-five(25)calendar days of the month following service in order to receive payment. Failure to submit in a
timely and complete manner shall result in forfeiture of payment.
5. In the event no service fees are incurred during the service month, an Authorization for Contractual Services
stating no services were provided for that service month shall be submitted within twenty-five(25)calendar days
following the month of service.
6. Work with family to prepare to pay for services beyond established time frame.
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. The billing must include all forms designed for Child Welfare Administration funding
reimbursement and approved by the Department of Social Services including Colorado State
Department of Social Services Authorization for Contractual Services form and Weld County
Monthly Request for Reimbursement under Core Service Funding.
7. 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;
8. Will meet with Social Services FPP Supervisor quarterly(more if needed)to review program usage and
effectiveness to discuss necessary improvements to better serve families or increase referrals;
9. Be available to meet with DSS staff to explain program,time lines of response to referrals and answer questions
to enhance program.
10. Be available for the Families,Youth and Children Commission review and attendance at the FYC meetings.
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Contract Number 05 CORE-51
5310.213 (2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
1. WET IT COT TNTY DATE:
2.
Name of Provider
3.
Address
4.
City, State, Zip
THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED:
5.
Name of Client Household# Cat. Cat. Grp.
6.
Description Sv. Code
7.APPROVAL:
Caseworker Date Co.Director or Supervisor
8.TO BE COMPLETED BY PROVIDER
DATE OF SERVICE
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 COUNTY DEPARTMENT OF
SOCIAL SERVICES INDICATED.
Provider Signature Date
Prepare in Triplicate,Original and One copy to Provider, One Copy for Pending File.
Completed Provider's Forms-Original to County Finance Office-Copy to Case Record.
Contract Number 05 CORE-51
WELD COUNTY MONTHLY REQUEST FOR REIMBURSEMENT UNDER CHILD WELARE REGULAR ADMINISTRATION FUNDING
Remit to: Elaine Furister,CPS/CAP,Core Services Specialist
Name of Program Month of Service Weld County Department of Social Services
Notice to Providers: List all clients currently enrolled in your program. P.O.Box A, 315 B N 11 Avenue,Greeley,CO 80632
Enter 0 if no services were provided during billing month Telephone: 970.352.1551,extension 6295
FAX: 970.346.7698
Client Name HH# Referral# Approved Approved Date of Actual Rate per Total Payment Social Services Payments Services
(If Entry Exit Date Service Hrs/Units Unit Requested Only-Comments Denied/Delayed Payable
applicable) Date
•
Social Service Codes: CE-Computation Error;NR-No Referral; EED-Exceeds End Date; EMH-Exceeds Maximum Hours; EMS-Exceeds Maximum Sessions;
NP-Not Payable;
PD-Payment Delayed; SPD; Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;
PR-Progress Report Needed
Community Reach Center
Mental Health Evaluation Report—CORE
Referral Name: IntakeDate:
Case worker Name:
A general mental health evaluation was completed for the above noted client per your referral.
The following provisional information is being provided for your records and to assist you in
determining service planning. This information has been obtained from:
Self report Parent report Education records Family Service Plans
other treatment records. No formal psychological testing was administered. This
information should not be used as a predictor of dangerous behavior.
Diagnostic Impressions:
Adjustment Disorder Personality Disorder
_Anxiety Disorder _Substance Abuse
_Bipolar Disorder _Substance Dependence
Depressive Disorder Post-Traumatic Stress Disorder
_Impulse-Control Disorder _Relational Problems
Attention Deficit Disorder _Oppositional/Conduct Disorder
Other
It is the evaluator's opinion that the symptoms listed below may or may not affect this
consumer's ability to parent in the following manner:
Treatment Recommendations:
_Individual Therapy
Group Therapy
Family Therapy
Parenting Classes
_Psychiatric Evaluation/Possible Medication Management
Formal Psychological Evaluation
_Substance Abuse Treatment
Mental Health/Substance Abuse Treatment(Dual Diagnosis Treatment)
_No treatment recommendations at this time.
It is the evaluator's opinion that the recommended treatment will help the consumer with the
symptoms identified in the following manner:
Comments:
Evaluation and report completed by:_ Ph#
Follow-up Contact: Ph#
Fax to Carol Johnson @#303-412-5321. (phone# 303-412-5293)
CORE Mental Health Evaluation Guidelines
1. Read Family Service Plan prior to doing intake.
2. Complete intake.
3. Fill out the form Community Reach Center Mental Health Evaluation Report—
Core.
4. Fax to Carol Johnson. 303-412-5321.
Please remember when doing these intakes to consider how the Client's symptoms or stressors
may affect their ability to care for their children or keep them safe.
Fax to Carol Johnson @#303-412-5321. (phone# 303-412-5293)
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