HomeMy WebLinkAbout20050133.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - ISLAND GROVE REGIONAL TREATMENT CENTER
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 Island Grove
Regional Treatment Center,commencing December 1,2004 and ending May 31,2005,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 Island Grove
Regional Treatment Center, 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 10th day of January, A.D., 2005, nunc pro tunc December 1, 2004.
���� BOARD OF COUNTY COMMISSIONERS
EL
/�'(/// WELD COUNTY, COLORADO
' iii I' ,t` .,� p William H. erke, Chair
A4a r d t : erk to the Board
®� �) M. J le, Pro-Temp
puty Cler to the Board ''&I
Da id E.
Long
AP D AS TO FO ���✓
Robert Masden
ourffy`zC�! ney7 �b lr
Glenn Vaad
Date of signature:
2005-0133
SS0032
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DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY,CO 80632
' WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
111 C Child Support(970)352-6933
COLORADO
MEMORANDUM
TO: William H. Jerke, Chair Date: January 4, 2005
Board of County Commissioners
FR: Judy A. Griego,Director, Social Services a 9tut,
RE: Child Protection Agreement for Services A` reement Between
the Weld County Department of Social Services and Island
Grove Regional Treatment Center
Enclosed for Board approval is a Child Protection Agreement for Services between the Weld
County Department of Social Services (Department) and Island Grove Regional Treatment
Center(Island Grove). This Agreement was reviewed at the Board's Work Session of June 28,
2005.
The major provisions of the Agreement are:
1. The term of the Agreement is December 1, 2004 through May 31, 2005.
2. The source of funding is Child Welfare Regular Administration funding.
3. Island Grove agrees to monitor sobriety for immediate referrals and to provide substance
abuse treatment services to child welfare clients upon the depletion of Core funding and
Additional Funding Services (AFS) funding assigned to Signal, the statewide
Management Care Organization.
4. The Department agrees to reimburse Island Grove a maximum of$120,000 for services
according to the fee schedule provided in the Agreement.
If you have any questions,please telephone me at extension 6510.
2005-0133
Contract Number 04-CPS-33
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND ISLAND GROVE REGIONAL TREATMENT CENTER,INC.
This Agreement, made and entered into the day of January 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 Island Grove Regional Treatment Center, Inc., hereinafter referred to as
"Island Grove."
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 Child Welfare Regular Administration
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 adults and youth; 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
Additional Funding Services(AFS)funding; and
WHEREAS, Island Grove 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 and is willing and able to provide such services required by Social Services.
NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
This Agreement shall become effective on December 1,2004,upon proper execution of this Agreement and
shall expire May 31,2005, unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by Island Grove 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 Child
Welfare Regular Administration funds during the duration of this Agreement.
Island Grove,in accordance with federal HIPPA regulations, will be adopting or has adopted the
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Contract Number 04-CPS-33
standard transaction code set for all treatment services. Even though this compliance will change the
service labels and groupings,the net fees associated with those services will not change.
b. Island Grove shall submit an itemized monthly bill to Social Services for all costs incurred and services
provided pursuant to Exhibit A of this Agreement and in accordance with criteria established by Social
Services. Island Grove 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
Child Welfare Regular Administration 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, Island Grove 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
Child Welfare Regular Administration 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. Island Grove 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 Island Grove has failed to comply with the Financial
Management Requirements,program objectives,contractual terms,or reporting requirements. In the event
of a forfeiture of reimbursements,Island Grove may appeal such circumstance to the Director of Social
Services. The decision of the Director of Social Services shall be final.
6. Assurances
Island Grove 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, Island Grove 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. Island
Grove 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
C.F.R.Part 84;and
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Contract Number 04-CPS-33
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,Island Grove 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
Island Grove 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
Island Grove and Social Services agree that monitoring and evaluation of the performance of this Agreement
shall be conducted Island Grove and Social Services. The results of the monitoring and evaluation shall be
provided to the Board of County Commissioners,Weld County,and Island Grove.
Island Grove shall permit Social Services, and any other duly authorized agent or governmental agency, to
monitor all activities conducted by Island Grove 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 Island
Grove 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 Island Grove. These
remedial actions are as follows:
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Contract Number 04-CPS-33
a. Withhold payment to Island Grove 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 Island Grove 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 Island Grove due to omission, error,fraud,and/or defalcation shall be recovered from
Island Grove by deduction from subsequent payments under this Agreement or other agreements between
Social Services and Island Grove,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 Manager 4
Name Title
For Island Grove:
B.J.Dean Executive Director
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: Island Grove
Judy A. Griego,Director B.J.Dean,Executive Director
P.O.Box A 1140 M. Street
Greeley,CO 80632 Greeley,CO 80631
14. Litigation
Island Grove shall promptly notify Social Services in the event that Island Grove learns of any actual litigation in
which it is a party defendant in a case that involves services provided under this Agreement. Island Grove,
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. Island Grove reserves the right to suspend services to clients if funding is no longer
available.
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Contract Number 04-CPS-33
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
E /Ida%
BOARD OF COUNTY
1861 E ARD COMMISSIONERS WELD
1+ <'� COUNTY,COLORADO Fcy, it , J D ler William H.Jerke, Chair 1/10/2005
ED AS ISLAND GROVE REGIONAL TREATMENT CENTER, INC.
____--
BY
only mey B.J. ean,Executive Director
WELD COUNTY DEPARTMENT
OF SOCIAL S R CES
By:
Judy . Grie ,Dire to
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DOS—O/3.-
Contract Number 04-CPS-33
EXHIBIT A
SCOPE OF SERVICES
1. Service Fee Schedule
Island Grove will charge Social Services for services to child welfare clients according to a Service Fee Schedule
as follows:
Description Fees
Antabuse Monitoring $2.00 each
Breathalyzer $2.00 each
Court testimony $75.00 per hour
Detox $185.00 per day
Detox—Extended Stay $50.00 per day
Drug Patch including monitoring and evaluation with confirmation $50.00 each
Evaluation—Substance Abuse with UA $155.00 each
Evaluation—Co-occurring alcohol and drug with domestic violence $175.00
Evaluation—Domestic violence $135.00 each
Family Session $100.00 per hour
Group Session $15.00 per hour
Individual Session $60.00 per hour
IOP—Adolescent(Fast Track) $50.00 per hour
IOP—Adolescent Residential Support Services $120.00 per day
IOP Group-Adult $25.00 per hour
On-site Staff Services or other staff services equivalent to on-site services and pre- $40.00 per hour
approved by Social Services
Transitional Residential $128.00 per day
UA-3 panel $12.00 each
UA-7 panel $12.00 each
UA Confirmation(GCMS) $35.00 each
Evaluation off-site $200.00 each
Vapor inhalations evaluation includes confirmation $40.00 each
Swab $15.00 each 6-
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Contract Number 04-CPS-33
On-Site Staff Services Island Grove On-Site Evaluator's time at Social Service will be reduced as this
service is phased out during the term of the Agreement. Substance abuse
evaluations that are completed at the Island Grove facility will be billed as a fee
for service as provided within the Agreement. The On-Site Adolescent
Evaluator will be trained and utilized by Social Services in completing adult
substance abuse assessments. Social Services will not be billed for hours that
the staff person is not on-site due to illness,vacation, educational leave,etc.
Island Grove On-Site staff person shall be responsible for:
a. Delivering completed Island Grove evaluations for outpatient and intensive
outpatient treatment to Ms. Elaine Furister, Core Services Specialist, or
designee.
b. Delivering completed Island Grove evaluations for any other higher level of
care than outpatient/intensive outpatient treatment to Mary Gill, Substance
Abuse Core Services Manager,or designee.
c. Distributing all substance abuse service authorizations to the appropriate
Island Grove staff to expedite services to Social Services clients.
Assessments All assessments will be paid for through the Social Services CORE service
contract. Signal contract provider will deliver the completed evaluation to
Social Services within two weeks of the client's evaluation meeting with the
staff person. All assessments shall include documentation of at least two
collateral contacts to confirm/refute client self-reported information.
Residential Youth residential services may be billed to core,as negotiated on a case-by-case
basis.
Adult Treatment Adult treatment,case management and after care(45-60 days).
Services
Ongoing Treatment Ongoing treatment services will be assigned to funding streams according to
usage, as negotiated on a case-by-case basis.
Youth Services Youth in Conflict(YIC) cases may be eligible for services through Core Service
dollars, as negotiated on a case-by-case basis.
2. Measurable Outcomes and Objectives
Island Grove 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. Outcome Reports as Prescribed by Social Services
Quarterly Outcome reports will be provided to Social Services and will include the following:
1) Number of clients served;
2) Number of clients currently in each level of care;
3) Number of clients that have successfully completed their treatment. This will be broken down
into each level of care primary;
4) Number of clients that no showed, were unsuccessfully discharged or moved to a higher level
of care. This will be broken down by level of care primary;
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Contract Number 04-CPS-33
5) Number of clients served whose primary addiction is to methamphetamine;
6) Number of clients served with a dual diagnosis, including the client's primary mental health
diagnosis;
7) Percentage of client progress delineated by each outcome objective as described under Item 5,
C of the Agreement.
B. Client Objectives
The Social Services caseworker will identify a maximum of three child welfare objectives to be
addressed within each client's treatment plan. Island Grove shall develop action steps to reach the
identified child welfare objectives. Island Grove 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.
C. Overall Program Objectives
Island Grove and Social Services agree to monitor the ability of the substance abuse program offered by
Island Grove to achieve objectives as follows:
1) Demonstrate Abstinence with the use of LTA/Patch Monitoring Only (Code#100).
2) Improve parental capabilities currently impaired by substance abuse(Code#10I).
3) Develop the capacity to ask for help and assistance without resorting back to substance
abuse(Code#102).
4) Develop or increase the ability to recognize,prioritize and meet child(ren)'s needs(Code
#103).
5) Parent will identify how their substance use has affected their parenting(Code#104).
6) Parent will identify how their substance use got them involved with social services(Code
#105).
7) Parent will identify how their substance use helped them parent(Code#106).
8) Parent will identify relapse triggers and develop a safety plan for their children(Code#107).
9) Parent will identify whom they consider to be a support in their recovery(Code#108).
10) Parent will identify who will care for their children should they relapse (Code#109).
11) Parent will identify what they enjoy about parenting sober(Code#110).
12) Improve parent-child functioning to lower the risk of out of home placement(Code#201).
13) Parent will support their children in speaking about how living in a substance-effected family
has impacted them(Code#202).
14) Parents will demonstrate increased verbal skills, empathy and accountability with child(ren)
(Code#203).
15) Parent will identify their parenting strengths(Code#204).
16) Family members including significant other,children and extended family will increase ability
to communicate more effectively(Code#301).
17) Family members will identify how they can support the identified client in their recovery
(Code#302).
18) Family members will identify the positive parenting changes the substance-effected person is
making(Code#303).
19) Family members will identify who will care for the children in the event of a relapse(Code
#304).
20) Family members will identify relapse systems of the identified client(Code#305).
21) Family members will identify how they can reach out for help if a relapse occurs(Code#306).
22) Increase level of functioning currently impaired by living in a substance affected family(Code
#401).
23) Identify how living in substance effected family has impacted their life (Code #402).
24) Improve level of functioning currently impaired by substance abuse issues (Code#403).
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Contract Number 04-CPS-33
EXHIBIT C
ASSURANCES
1. Island Grove 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 Island Grove or its employees,
volunteers, or agents while performing duties as described in this Agreement. Island Grove shall indemnify,
defend, and hold harmless Weld County, the Board of County Commissioners of Weld County,its employees,
volunteers, and agents. Island Grove 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 Island
Grove 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. Island Grove 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. Island Grove 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 Island Grove.
9. All such records,documents, communications,and other materials shall be the property of Social Services and
shall be maintained by Island Grove,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. Island Grove 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 04-CPS-33
25) Decrease aggressive behaviors at home and/or school and in the community(Code#404).
26) Learn how to socialize without the use of substances(Code#405).
27) Identify relapse triggers(Code#406).
28) Create a sober support network(Code#407).
3. Staff Qualifications
Island Grove staff members who will provide services to Social Services clients will have credentials and/or
certifications as required by the Colorado Department of Human Services,Colorado Board of Education,
Alcohol and Drug Abuse Division,and the Colorado Board of Medical Examiners.
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Contract Number 04-CPS-33
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to Island Grove in consideration for the work and services performed, a total
amount not to exceed One Hundred Twenty Thousand Dollars($120,000.00) including a 5%administrative fee
not to exceed$6,000 and under Child Welfare Regular Administration funding. Island Grove and Social
Services agree to expend Additional Family Services (AFS)and Core Services funding prior to requesting
reimbursement through this Agreement.
Expenses incurred by Island Grove, 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 Child Welfare Regular Administration funds, whether in whole or in part,
is subject to and contingent upon the continuing availability of Child Welfare Regular Administration 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 will authorize payment of$20 per each missed appointment by a client for up to 3 missed
appointments or a cap of$60 per client.
Social Services referrals will not be sent to collections by Island Grove 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.
Island Grove 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, Island Grove 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
Island Grove 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 04-CPS-33
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.
Island Grove or Social Services may not assign any of its rights or obligations hereunder without the prior
written consent of both parties.
12. Island Grove certifies that federal appropriated funds have not been paid or will be paid,by or on behalf of
Island Grove,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. Island Grove assures that it will fully comply with all other applicable federal and state laws. Island Grove
understands that the source of funds to be used under this Contract is Child Welfare Regular Administration
funds.
14. Island Grove 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
Island Grove 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, Island Grove 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, Island Grove 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 Island Grove.
16. Island Grove 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 Island Grove shall be
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Contract Number 04-CPS-33
disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance
with Island Grove written policies governing access to,duplication and dissemination of, all such information.
Island Grove shall advise its employees, agents, and subcontractor, if any, that they are subject to these
confidentiality requirements. Island Grove 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 Island Grove
in the course of providing services under this Contract will be accorded at least the same precautions as are
employed by Island Grove 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.
Page 3 of 3
Contract Number 04-CPS-33
EXHIBIT D
CHILD WELFARE ADMINISTRATION FUNDS
STANDARDS OF RESPONSIBILITY
Island Grove agrees to:
1. Accept referrals for services from Social Services according to conditions and approval process for referrals as
follows:
a. Social Services caseworker will initiate the referral for substance abuse evaluations and treatment.
b. Elaine Furister, Core Services Specialist, or designee,will authorize the transmittal of all referrals,as
required through a substance abuse referral form, for evaluations and substance abuse outpatients and
intensive outpatient treatment.
c. Mary Gill, Substance Abuse Core Services Supervisor,or designee, will authorize and approve
substance abuse services that are beyond the scope of outpatients and intensive outpatient treatment.
d. The substance abuse referral form, as authorized and provided by Social Services,will serve as the
authorization for evaluations and all other substance abuse services. The substance abuse referral form
will identify the level of care that is authorized, a referral ID number, and the time period that services
may be provided by Island Grove.
2. Submit requests for renewal of substance abuse services according to conditions and approval process for such
renewals as follows:
a. Island Grove may request a renewal of substance abuse services through a monthly brief report, as
referenced in Exhibit D, Item 3, Item 5, and Item 8.
b. Joyce Hause,Caseworker IV, or designee,will authorize renewal requests for outpatient and intensive
outpatient services.
c. Joyce Hause,Caseworker IV, and Mary Gill, Substance Abuse Core Services Supervisor, or designees,
will authorize renewals request for Transitional Residential Treatment or other non outpatient and
intensive outpatient services.
d. The substance abuse referral form,as authorized and provided by Social Services,will serve as the
authorization for renewal of service requests by Island Grove. The substance abuse referral form will
identify the level of care that is authorized,a referral ID number, and the time period that services may
be provided by Island Grove.
3. Report to Social Services a monthly brief report on the status of the client's treatment as prescribed by Social
Services.
4. Report to Social Services expenditures and case disbursement at agreed upon times.
5. Submit monthly-completed billing forms to Ms. Elaine Furister, Core Services Specialist, or designee within
twenty-five(25)calendar days of the month following service in order to receive payment. Failure to submit in a
Page 1 of 2
Contract Number 04-CPS-33
timely and complete manner shall result in forfeiture of payment. To allow for payment by Social Services
within 60 days, Social Services requests that completed billings be submitted to Social Services by Island Grove
on or about the 10th day of the month after the moth services were provided.
6. In the event no service fees are provided 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.
7. Work with family to prepare to pay for services beyond established time frame.
8. 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 Child Welfare Administration Funding. This billing requirement extends to any
On-Site Staff services provided by Island Grove, which requires that hourly services be documented
through the Weld County Monthly Request for Reimbursement form.
9. 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.
10. 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.
11. Be available to meet with Social Service's staff to explain program, time lines of response to referrals and
answer questions to enhance program.
12. Be available for the Families, Youth and Children Commission review and attendance at the FYC meetings.
Page 2 of 2
Contract Number 04-CPS-33
5310.213(2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL 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.
Contract Number 04-CPS-33
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 prograrh. 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
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