HomeMy WebLinkAbout20053593.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - COLLABORATIVE SERVICES FOR CHANGE PC
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 Collaborative
Services for Change PC,commencing September 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 Collaborative
Services for Change PC 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 12th day of December, A.D., 2005, nunc pro tunc September 1, 2005.
BOARD OF COUNTY COMMISSIONERS
]EL.e� WELD COUNTY, COLORADO
ATTEST: LEM
�� ��•,,,. I� ir%_
dliam H. Jer , Chair
Weld County Clerk to the 1•- • ''%+ �y
/��� M n M. J. Ile, P o- em
BY: �' � �U�l
D uty CI k to the Bo=
Da 'd E. Lon
,I,tOaD AS TO RM:
Rob prx D. Masd
Cou6ty Attorney /2L/1/
Glenn Vaad—
Date of signature: 1112-005
2005-3593
SS0032
0e - SS O/- OS-c9
(7se ct I %% DEPARTMENT OF SOCIWebsite:www.co.weld.co.us
igl ' Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
C.
COLORADO
MEMORANDUM
TO: William H. Jerke, Chair Date: December 5, 2005
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services (1 I
RE: Child Protection Agreement for Services etween the Weld County
Department of Social Services and Collaborative Services for Change PC Group
Enclosed for Board approval is a Child Protection Agreement for Services between the Weld
County Department of Social Services(Department) and Collaborative Services for Change PC
Group (Provider). This Agreement was reviewed at the Board's Work Session held on November
21, 2005.
The major provisions of the contract are as follows:
f
1. The term of the contract is September X18, 2005 through May 31, 2006.
2. The source of funding is Core Services or Child Welfare Administration funding.
3. The Provider will provide mental health therapy for a child specific case in the child
welfare system.
4. The Department will reimburse the Provider at a rate of$450.00 per month including 1.5
clinical hours at $75 per clinical hour.
If you have any questions,please telephone me at extension 6510.
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2005-3593
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Contract No: 05-CORE-50
CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN
THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES AND
COLLABORATIVE SERVICES FOR CHANGE PC GROUP
This Agreement is made and entered into the day of October,2005,by and between the Board of ,
County Commissioners, on behalf of Weld County Department of Social Services;hereinafter referred to as"Soc al
Services," and Collaborative Services For Change PC,hereinafter referred to as the "Provider."
WITNESSETH
WHEREAS,required approval,clearance and coordination have been accomplished from and with
appropriate agencies; and
WHEREAS,the County of Weld,pursuant to the Weld County Home Rule Charter,has provided
Core Services fund resources for Therapeutic Intervention under the Intensive Family Therapy Program area; and
WHEREAS, Social Services desires to enter into an agreement with the Provider to assist Social Services in
providing Therapeutic Intervention under the Intensive Family Therapy Program.
NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows:
1. Terms
This Agreement shall become effective on September 1,2005,upon proper execution of this Agreement
and shall expire May 31,2006.
2. Scope of Services
Services shall be provided by the Provider through Weld County Department of Social Services, in
compliance with Exhibit A"Scope of Services," a copy of which is attached and incorporated by reference.
3. Payment Schedule
a. Payment shall be made on the basis of Exhibit B, "Payment Schedule," a copy of which is attached
and incorporated by reference.
The `Payment Schedule' shall establish the maximum reimbursement,which will be paid from
Core funds during the duration of this agreement.
b. The Provider shall submit an itemized monthly billing to Social Services for all costs incurred
pursuant to Exhibit A 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. Billings must be original
and contain the original signature of the Provider or its designee.
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Contract No: 05-CORE-50
c. Failure to submit monthly billings in accordance with the terms of this agreement shall result in the
Provider's forfeiture of all rights to be reimbursed for such expenses. In the event of forfeiture of
reimbursement,the Provider may appeal such circumstance to the Director of Social Services. The
decision of the Director of Social Services shall be final.
d. Payments to the Provider shall be made monthly by Social Services upon receipt of such itemized
billings as required under Exhibits A and B.
e. Payment of costs incurred pursuant to this Agreement is expressly contingent upon the availability
of Core Services funds to Social Services.
f. 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,the 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 Emergency Assistance Program under the Colorado Family Preservation Act 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. The Provider shall provide proper monthly invoices and verification of services,as identified in
attachment Exhibit D,performed for costs incurred in the performance of the agreement.
b. Social Services may withhold any payment if the 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,the Provider may appeal such circumstance to the
Director of Social Services.The decision of the Director of Social Services shall be final.
6. Assurances
The Provider 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 Laws
At all times during the performance of this contract,the Provider shall strictly adhere to all applicable
federal and state laws, orders, and all applicable standards, regulations, interpretations or guidelines issued
Page 2 of 5
Contract No: 05-CORE-50
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. The 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
-the Education Amendments of 1972;and
-Immigration Reform and Control Act of 1986,P.L. 99-603;
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
The Provider and Social Services agree that monitoring and evaluation of the performance of this
Agreement shall be conducted by the Provider and Social Services. The results of the monitoring and
evaluation shall be provided to the Board of Weld County Commissioners.
The 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 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.
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Contract No: 05-CORE-50
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
the 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 the
Provider. These remedial actions are as follows:
a. Withhold payment to the 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 the 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;
c. Incorrect payment to the 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 the 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: For the Provider:
Judy Griego,Director Jeff Kisicki, LCSW
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:
Judy A. Griego,Director Collaborative Services For Change PC
P.O.Box A 2480 W,26th Avenue, Suite 130-B
Greeley,CO 80632 Denver, CO 80211
Phone: 303-433-0188,fax: 303-433-6145
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Contract No: 05-CORE-50
14. Litigation
The Provider shall promptly notify Social Services in the event that the Provider learns of any actual litigation
in which it is a party defendant in a case which involves services provided under this Agreement. The 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 finding.
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.
TN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first
above written.
ATTEST:
Weld County Clerk to the Board I _ `' ' i OF COUNTY COMMISSIONERS
ift
I AIM . '' COUNTY, COLORADO
tifBy: - �utediu_ 1,tRit i.""/ •
•
D 'uty Cl- k ♦ �, William H. Jerke,Chair
4* ffiFly% I� DEC 12 2005
APPROV AS TO FO
FOR PROVIDER:
County Attorney
By: ' Ctsiv
J Kisicki,LCSW
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: ,$QQector .
Page 5 of 5
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Contract No: 05-CORE-50
EXHIBIT A
SCOPE OF SERVICES
Project Description:
To support less restrictive alternatives for Weld County children with severe emotional and behavioral
disorders through maintaining children in specialized foster homes and decreasing the need for residential
treatment and hospitalization.
2. Type of Services to be Provided:
1. Training:Transitions would provide intensive training to teach foster parents parenting skills proven
effective with severe emotional and behavioral disorders. The training would consist of 12 hours of
instruction and practice sessions.On-going training seminars will also be available based on the needs
of the foster parent families.
2. Therapy: Individual and family therapy services will be provided to treat the emotional and
behavioral disorders and address family dynamics. These services will be provided in the home,at
Transitions offices or in other community settings(i.e.the child's school)as needed.
3. Crisis Intervention: Transitions will have a counselor accessible to the foster families outside business
hours to assist with managing difficult situations and provide alternatives to law enforcement
intervention and hospitalization. A therapist will be on call 24-hours per day, seven days per week.
4. Case Management:Transitions counselors will participate in a monthly staffing with Social Services,
other service providers and each foster family to monitor progress towards goals and provide support
and consultation.
Level of Service:
The level of service depends on the needs of the primary client and the foster family in accordance with
program objectives. All levels include on-call support.
Level A:Intensive level of service ranging from 7-10 hours of direct service per week. Level A incorporates
all types of services including therapy,crisis intervention,and case management.
Level B: Moderate level of service ranging from 4-6 hours of direct service per week. Level B incorporates
all types of services including therapy, crisis intervention,and case management.
Level C:Minimal level of service ranging from 2-3 hours of direct service per week. Level B incorporates
all types of services including therapy, crisis intervention,and case management.
Page 1 of 1
Contract No: 05-CORE-50
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to the Provider, in consideration for the work and services performed,a
total amount of$90.00 per hour,which includes all services described on attached Exhibit A. The source of
funds to be reimbursed to the Provider is Core Services Funds under the Emergency Assistance Program
under the Colorado Family Preservation Act.
Expenses incurred by the 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, if Weld County funds,whether in whole or in part, is subject to and
contingent upon the continuing availability of Weld County funds for the purpose 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 the Provider $75.00 per clinical hour, per week, for a total monthly cost of
$450.00 for the services provided for the term of this contact, September 1,2005, through May 31, 2006.
The Provider understands he will only be reimbursed for direct client, fact-to-face contact.
The Provider understands that he will not be reimbursed for any preparation time,travel time,report writing,or
other activities that do not include fact to face client contact.
The Provider's billing is a tenth of an hour and billing statements will be sent after each medication,with the
Contactor requesting payment within thirty(30)days after billing date.
3. Submittal of Vouchers
The Provider shall prepare and submit monthly the itemized voucher and certify through signed client
verifications that the services authorized were provided on the date indicated and the charges made were
pursuant to the terms and conditions of Exhibit A. The signed verification shall include the date and hour(s)
of service and an original client signature verifying the service,and shall be submitted with the itemized
voucher.
The Provider must agree to:
a. Provide written recommendations or action plan in the client's primary language for all
monolingual clients.A copy of the recommendations or action plan should be sent to Ms. Elaine
Furister,CPS/CAP,Core Services Specialist, at Weld County Department of Social Services,P.O.
Box A,315 N 11 Avenue,Greeley,CO, 80632.
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Contract No: 05-CORE-50
b. Provide a case management plan on each referred family within 30 days of the date the Provider
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 Ms. Elaine Furister,CPS/CAP, Core Services Specialist,
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.
c. Provide a monthly client progress report as above within twenty-five(25)working day
immediately after the month of service.The monthly progress report must be attached to the
monthly billing for payment to be honored.Failure to submit such monthly reports will result in
delays or forfeiture of payment.
Monthly Reports-will be submitted no later than twenty-five(25) working days past the end of the
month of service. It is expected, at a minimum,that these reports will reflect:
-presenting problem(s)of the client/family,
-specific services provided,
-extent of client(s)participation and commitment to program,
-client(s)progress to date,
-anticipated discharge date.
d. Report to Social Services a monthly brief report on the status of the program as prescribed by
Social Services;
e. Submit a final narrative summary of program outcomes to Social Services within 30 days after the
completion date;
f. Report expenditures and case disbursement at agreed upon times.
g. Billing forms are to be submitted to Elaine Furister CPS/CAP on or about the 10th of the month
after the month the services were provided. All billings must be date-stamped by the Department
by the 25th day of the month following service to be eligible for reimbursement. Billings received
and date-stamped after the 25th day of the month will not be honored.
h. The provider shall submit signed, original billing forms, including all documentation
required to verify services provided during the service month. The completed billing
forms must be received by Social Services no later than the 25th day of the month following the
dates of service.
No billing forms or documentation will be accepted by the Department for processing after the 25th
day following the service month. All items submitted after this date shall be returned to the
provider unpaid. Further,the Department will not consider payments that were originally reviewed
as deficient in documentation for future reimbursement.
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 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,time of
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Contract No: 05-CORE-50
service and hours of service provided,and names of clients receiving the services.
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, as stated in the Notification of Financial Assistance.
The above items, i, 1, 2,3,will supersede all requests from providers for review of billing
errors. Items submitted for billing will be processed according to the criteria established
by the above documentation.
An Administrative fee may 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.
j. 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. (See
Attachment A of the Request for Proposal):
1) The billing must be an original billing signed by the provider and/or designee.
2) The billing must include all forms designed for Core Services reimbursement and
approved by the Department of Social Services;Core Services Authorization of Funds,
Project Report,Update Report,and signed client verifications for each client serviced
during the billing period.
3) Each client who has a current referral,both receiving services and not receiving services
during the service month,must be listed on the billing form.A service summary must be
provided by the provider for clients who have active referrals during the billing month in
order to direct issues to the caseworker and court.
a. Core Services Authorization forms must be submitted completely filled in with an
original signature from the provider and/or designee.
b. Reports must include the client's full name, Weld County Case ID, Weld
County Referral number,hours served,hourly rate,and total billed for the month
the service was provided.
c. Verification forms must include the client's original signature at the time of
service,date of service,hours served,Case ID and Core service referral number.
d. Payment through Core Services Program funds will be made only for direct
client contact with the appropriate identifying client signature included on the
verification form.
k. 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;
1. 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;
m. Be available to meet with DSS staff to explain program,time lines of response to referrals and
answer questions to enhance program.
n. Be available for the Families,Youth and Children Commission review and attendance at the FYC
meetings. Page 3 of 3
Contract No: 05-CORE-50
EXHIBIT C
ASSURANCES
1. The 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 indemnify,defend,
and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees,
volunteers,and agents. The 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, the
Provider shall provide Social Services with the acceptable evidence that such coverage is in effect.
3. No portion of this Agreement 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 Agreement 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 Agreement 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 Agreement 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. The Provider 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 Agreement.
8. The 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 Agreement 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 the Provider.
9. All such records,documents,communications,and other materials shall be the property of Social Services and
shall be maintained by the 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 maybe
necessary to resolve any matters which may be pending,or until an audit has been completed with the following
Page 1 of 3
Contract No: 05-CORE-50
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. The 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 Agreement 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 Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and
assigns. The Provider of Social Services may not assign any of its rights or obligations hereunder without the
prior written consent of both parties.
12. The Provider certifies that Federal appropriated funds have not been paid or will not be paid,by or on behalf of
the 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. The 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. The Provider understands that the source of funds to be
used under this Agreement is: Social Services Funds.
14. The 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;
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 Agreement,had one or more public transactions
(federal,state, and local)terminated for cause or default.
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Contract No: 05-CORE-50
15. The Appearance of Conflict of Interest applies to the relationship of a Provider with Social Services when the
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 the 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,the 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 the
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 sub Providers, if any, that they are subject to these confidentiality
requirements. Provider shall provide its employees, agents, and sub Providers, 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 the Provider in the course of providing services under this Contract will be
accorded at least the same precautions as are employed by the Provider for similar information in the course of
its own business.
18. The Provider certifies it will abide by Colorado Revised Statue (C.R.S.) 26-6-104, requiring criminal
background record checks for all employees,Providers, and sub-Providers.
Page 3 of 3
Contract No: 05-CORE-50
EXHIBIT D
BILLING FORMS/CLIENT VERIFICATION
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTURAL SERVICES
5310.213 (2/79)
1. WELD COUNTY 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 Date
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 No: 05-CORE-50
WELD COUNTY CORE SERVICES PROGRAM MONTHLY REQUEST FOR REIMBURSEMENT-PY 2004-2005
Remit to: Elaine Furister,CPS/CAP,Core Service 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 Actual Maximum Rate per Monthly Social Services Payments Services
Trails ID Entry Date Exit Date Hrs/Service Hours Unit Total Only-Comments Denied/Delayed Payable
Period Sessions/
Service
Period
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
WELD COUNTY CORE SERVICES PROGRAM PROJECT REPORT-PY 2004-2005
•
Contract No: 05-CORE-50
Remit to: Elaine Furister, CPS/CAP,Core Service Specialist
Weld County Department of Social Services
Program Month of Service P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Telephone: 970.352.1551,Ext.6295 FAX:970.346.7698
#Households Referred During #of Households Enrolled #of Households Served #of Households Discharged Monthly Expenditure Expenditures to Date
Month During Month During Month During Month
Termination Reason Codes: SEP-Successfully Ended Program; M-Moved; UL-Unable to Locate;RCCF-Entered a Residential Facility; FCR-Foster Care Review;OT-Explain,TM-Transferred to
Another Program More Restrictive;FC-Entered Foster Care;NT-Terminated;Unable to Work with Client;RH-Returning to Relative
Child's Name Direct Service Date Service Termination Client Caseworker Provider Initial Case Monthly Funding Total Cost Social
Date Ended Reasons Survey Survey Survey Management Progress Report Source of Program Services
Plan(Date) to Date Use
Funding Source: EPP-Expedited Permanency Planning;M-Medicaid;CI-Client Insurance;O-Other
•
Contract No: 05-CORE-50
CORE SERVICES PROGRAM YEAR 2004-2005-CLIENT VERIFICATION FORM
Notice to Provider:All clients served during the service month must complete this verification form at the time of service.No request for payment of services will be honored for billed services unless
accompanied by the appropriate signed client verification form. Payment for services will not exceed maximum hours or sessions as stated in provider's RFP.
Section I: (To be completed by the provider)
Primary Client billed: Trails ID Total Hours Billed
Household Number: Referral Number: Contact Person:
SECTION II(To be completed by client)
Client signatures must be signed at the time of service.Your signature verifies that services were provided by the service provider for direct face-to-face contact only,for the hours indicated.
Date Hours Number of Hours of Client/Participant Signature(Please have all those attending sign.In the case of a child who is not able to sign,please have
Please state hours of Service Provided someone sign for the child;i.e.,Sally Smith by Gregg Jones,Foster Parent
services;i.e., 1:00-
2:30
Notice to Provider: Attach all client verification forms to the monthly billing when submitting your request for Payment for Contractual Services.All Requests for payment must be received by the 25th
day of the month following service in complete form.
Send original signed billing and verifications to: Elaine Furister,CPS/CAP,Core Service Specialist,Weld County Department of Social Services
P.O. Box A,315 B N 11 Avenue,Greeley,CO,80632
Telephone: 970.352.1551,extension 6295;FAX:970.346.7698
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