HomeMy WebLinkAbout20051786.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, 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 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 June, A.D., 2005, nunc pro tunc June 1, 2005.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
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William H. J ke, Chair
' 1861 Clerk to the Board
Fis `/1 / Bile, ro-Tem
����� •uty Clerk to the Board
Da ' E. Long
•
APP AS TO
Robert . Masden
unty Attorney
Glenn Vaa
Date of signature: 7 O,
2005-1786
SS0032('C : c? -o -0S_
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DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website: www.co.weld.co.us
WI
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
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COLORADO
MEMORANDUM
TO: William H. Jerke, Chair Date: June 20, 2005
Board of County Commissioners -�
FR: Judy A. Griego, Director, Social Services / (.Lj a
-(V�
RE: Child Protection Agreement for Services Between the
Weld County 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 discussed and reviewed at the Board's Work Session of May 31,
2005.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is June 1, 2005 through May 31, 2006.
2. North Range will conduct psychological evaluation and assessment services for child
welfare families, children, and adolescents.
3. The Department agrees to reimburse North Range at a rate of$1,200 per each completed
evaluation including 40 hours of court testimony. Court testimony in excess of 40 hours
will be at a rate of$110 per hour. The total Core Services funding available under this
agreement is $97,544.
If you have any questions,please telephone me at extension 6510.
1
2005-1786
Contract No.PY 05-06-CORE-52
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 June 2005,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"North Range".
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 Mental Health Assessment and Services Agencies(MHASA);
and
WHEREAS,North Range is the MHASA for Weld County and is willing and able to provide mental health
services;and
WHEREAS, Social Services requires the services of a MHASA 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 North Range 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. Term
This Agreement shall become effective on June 1,2005,upon proper execution of this Agreement and shall
expire May 31, 2006.
2. Scope of Services
Services shall be provided by North Range 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. North Range 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 Contractor 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 05-06-CORE-52
Failure to submit monthly billings in accordance with the terms of this agreement shall result in
North Range forfeiture of all rights to be reimbursed for such expenses. In the event of a
forfeiture of reimbursement,North Range 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 is 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,North Range 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. North Range 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 North Range has failed to comply with the Financial
Management Requirements,program objectives,contractual terms, or reporting requirements. In
the event of a forfeiture of reimbursement,North Range may appeal such circumstance to the
Director of Social Services. The decision of the Director of Social Services shall be final.
6. Assurances
North Range 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,North Range 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. North Range 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
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Contract No.PY 05-06-CORE-52
the Equal Pay Act of 1963;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
North Range 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
North Range and Social Services agree that monitoring and evaluation of the performance of this
Agreement shall be conducted by North Range 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.
North Range shall permit Social Services,and any other duly authorized agent or governmental agency,to
monitor all activities conducted by the contractor 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
North Range 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 North
Range. These remedial actions are as follows:
a. Withhold payment to North Range 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 North Range 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 05-06-CORE-52
c. Incorrect payment to North Range due to omission, error,fraud, and/or defalcation shall be
recovered from Contractor by deduction from subsequent payments under this Agreement or other
agreements between Social Services and North Range,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:
Karen Thompson Interim Executive Director, North Range Behavioral
ayja, weir EALLutivc Diiectui,Noitl.Range Behaviotal Health- Health
Name t4 PIA 14 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.�((��
Karen Thompson,`"Tnterim Executive Director
Judy A. Griego,Director Wa,3.e L,ee.,at.se Dire t,r
P.O. Box A 1306 11`"Avenue w
Greeley,CO 80631 Greeley, CO 80631 Jt14414. Litigation
North Range shall promptly notify Social Services in the event that North Range learns of any actual
litigation in which it is a party defendant in a case, which involves services provided under this Agreement.
North Range, 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.
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Contract No.PY 05-06-CORE-52
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first
above written.
Sift
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WELD COUNTY BOARD OF COUNTY
•
• COMMISSIONERS
E mismist OARD WELD COUNTY,COLORADO
By:
4®6,N \ _ / •
William H. Jerke, Chair JUN 2 2 2005
,
P y
jDASr
iy Atfomey
WELD COUNTY DEPARTMENT NORTH RANGE BEHAVIORAL HEALTH
OF SOCIAL SERVI S
By: By:
J y A. sego, i ector -Way .c Muxa.ell Karen Thompson
U" Ex,e�.t:.e D.e.,t.,. Interim Executive Director
By: L i f 2j'4 l,'c Vet, 1 ncE l
Board Chairperson Michele Vetting
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07405 i20P
Contract No.PY 05-06-CORE-52
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 North Range 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 North Range 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:
a. Psychological Evaluation
North Range will provide an evaluation that will be available to families,children and adolescents
who are eligible and in need of evaluations,and other assessment services intended to provide
information needed by the staff of Social Services.The evaluation procedures will be designed to
produce useful responses to specific referral questions mutually developed by the licensed or
licensed eligible psychologist and Social Services' Caseworker assigned to the case. The parties
will also collaborate with contacts that need to be made prior to the completion of the evaluation.
North Range will provide Social Services a written report upon completion of the evaluation,
which clearly states methods used,contacts made, tests administered,results, and
recommendations relevant to the referral questions.North Range will administer and interpret tests
by staff who are certified or qualified to provide linguistically appropriate and culturally
competent testing. The content of this assessment will be made available to the family and other
relevant parties,subject to the American Psychological Association ethical standards and other
legal considerations.
North Range's evaluation can be useful in identifying significant mental health issues and
diagnoses,addressing personality issues, addressing intellectual functioning or the ability to
manage emotions, and treatment recommendations. The evaluation may be able to address issues
regarding placement of children with mental health issues and will consist, at a minimum, as
follows:
Review Social Services case records,prior evaluation and mental health treatment
records,police reports,medical records,records from other agencies involved in the case,
and, if applicable,North Range records; and
In depth clinical interview;and
Administration of emotional screening instruments,rating scales,measures of intellectual
functioning,and/or personality functioning, and/or parenting/family functioning as
necessary to answer the referral questions and make appropriate and meaningful
recommendations.
-- Consultation with collateral sources; and
-- Feedback given to the client; and
Write-up addressing psychosocial history,diagnostic information, all issues pertinent to
the referral questions,and treatment recommendations.
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Contract No. PY 05-06-CORE-52
b. Evaluation Referral
North Range evaluations will be assessed by the Social Services' caseworker and with any other
Social Services staff designated by Social Services. If North Range and Social Services agree,
through its staff,the evaluation requires additional testing or services resulting in additional
expenditures, the Social Services Manager 4 or his or her designee must expressly authorize in
writing to North Range to perform such testing or services.
c. Court Testimony
The licensed or licensed eligible psychologist providing the above services will be available for
court testimony when given proper notification,and such testimony is included in the rates
provided under evaluation rate for a maximum of 40 hours over the term of the contract. Court
testimony includes preparation of and actual court testimony.
3. Service and Pilot Objectives
North Range evaluations will prove beneficial to clients of Social Services by North Range'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 North Range and Social Services,
provided that the client can be reached for appointments and the client attends appointments as
scheduled.
b. Deadlines will be extended by Social Services on behalf of North Range when clients cannot be
found or reached.
c. If a client partially complies with appointments,North Range will write the evaluation based on
information obtained up to that date and prorated based on hours performed by North Range. If
no appointments have been made,the evaluation referral may be dropped by North Range due to
the client's failure to follow through and North Range will not bill Social Services.
5. Measurable Outcomes
North Range and Social Services wish to evaluate the quality and cost effectiveness of evaluations by
conducting two surveys of North Range evaluation staff and Social Services caseworkers during the term of
the Agreement and as identified by North Range and Social Services. The content of the survey will be
agreed upon by both parties.
6. Workload Standards
North Range will complete five(5)to ten(10)evaluations per month,depending on the level of evaluations
referred by Social Services.
7. Staff Qualifications
The North Range 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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Contract No. PY 05-06-CORE-52
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 North Range 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 North Range,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
Social Services agrees to reimburse North Range$1,200 for each completed evaluation as follows:
a. All evaluations referred to North Range will result in a write-up addressing psychosocial history,
diagnostic information,personality issues, intellectual functioning or emotional functioning and
regulation abilities,and treatment recommendations.
b. Any additional expenses for testing or other services must be expressly authorized in writing by
the Social Service Manager 4 or his or her designee.
c. Payment cannot be made unless the completed evaluation is attached to the bill for reimbursement.
d. Over the term of this Agreement North Range 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.
For partially completed evaluations, Social Services agrees to pay$60.00 per hour,not to exceed$300.00
per evaluation,and base such portion on the hours performed by North Range,as identified in the billing.
3. Standards of Responsibility
a. Social Services agrees to:
1) Contact North Range to schedule a face to face pre-referral staffing by North Range and
Social Services staff members for each referral to clarify background history and referral
questions.
2) At the pre-referral staffing provide North Range with the following:
a) Client's full name, address and phone number. If the client does not have an
address or phone, other contact information will be provided.
b) A completed psychological evaluation referral form.
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Contract No. PY 05-06-CORE-52
c) A copy of the Social Services background history report,Family Services Plan
and other documentation providing details of the case.
d) A copy of a signed HIPAA compliant release allowing the caseworker to
provide copies of documentation from other agencies with information
pertaining to the case(i.e., substance abuse evaluation and treatment records,
police reports,medical records,school records,copies of interactional
evaluations, copies of prior mental health evaluations copies of family treatment
records, etc.).
e) Complete copies of all the above as they pertain to the case.
b. North Range agrees to:
1) Attach copies of the completed evaluation at the time of billing 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.
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, State identification number,beginning and ending date of the referral,
completed or partial evaluation,hours performed for the partial evaluation,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 2S'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
North Range.
3) 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.
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 at
the FYC meeting.
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Contract No.PY 05-06-CORE-52
EXHIBIT C
ASSURANCES
1. North Range 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 North Range or its
employees, volunteers,or agents while performing duties as described in this Agreement. North Range
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,North Range 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. North Range 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. North Range 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 North Range.
9. All such records,documents, communications,and other materials shall be the property of Social Services
and shall be maintained by North Range, 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. North Range 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
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Contract No. PY 05-06-CORE-52
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. North Range or Social Services may not assign any of its rights or obligations hereunder without
the prior written consent of both parties.
12. North Range certifies that Federal appropriated funds have not been paid or will be paid,by or on behalf of
North Range,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. North Range assures that it will fully comply with the Children's Code regulations promulgated,and all
other applicable federal and state laws,rules and regulations. North Range understands that the source of
funds to be used under this Contract is:Family Issues Cash Funds.
14. North Range 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 contractor with Social Services when
North Range 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 North Range 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,North Range 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 North Range.
16. North Range 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 North Range
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Contract No.PY 05-06-CORE-52
shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian. North
Range shall have written policies governing access to, duplication and dissemination of, all such
information. North Range shall advise 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 North Range in the course of providing services under this Contract will
be accorded at least the same precautions as are employed by North Range for similar information in the
course of its own business.
18. North Range 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, contractors and
subcontractors whose employees have direct contact with children.
Page 3 of 3
Contract No.PY 05-06-CORE-52
310.213 (2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTURAL SERVICES
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
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.
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