HomeMy WebLinkAbout20031717.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES FOR ALCOHOL
AND DRUG TESTING OF ADULTS 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 for Alcohol and Drug Testing of Adults 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
July 1, 2003, and ending June 30, 2004, 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 for Alcohol and Drug Testing of Adults 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 2nd day of July, A.D., 2003, nunc pro tunc July 1, 2003.
BO RD OF COUNTY COMMISSIONERS
W COU TY, COLORAD
ATTEST: a&. i / << Ce
D vi E. Long, Chair
Weld County Clerk to r8sr •=IC ` ��
_�yrs j .
Robert D. sden, Pro-Tem
BY: / _•. ,"o, �_�
Deputy Clerk to the Bo-
M. J. Geile
APV AS TO • 1_4(
G aorneJW2W5k
Glenn Vaad
Date of signature: (t-
2003-1717
SS0030
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Contract Number 03-CPS-25
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND ISLAND GROVE REGIONAL TREATMENT CENTER
hd All
This Agreement,made and entered into the,2t— day of mco 2003,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,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 finding to Social Services for immediate referrals for monitored sobriety services for families,
children,and adolescents;and
WHEREAS,Social Services requires the services of a substance abuse treatment provider to assist the
County to deliver services for immediate referrals for monitored sobriety to child welfare clients,and Island Grove is
willing and able to provide such services;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.
NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
This Agreement shall become effective on July I,2003,upon proper execution of this Agreement and shall
expire May 31,2004,unless sooner terminated as provided herein.
2. genre of Services
Services shall be provided by Island Grove network providers to any person(s)eligible for child protection
services in compliance with Exhibit A"Scope of Services,"a copy of which is attached by reference.
3. Payment
a. Payment shall be made on the basis of Exhibit B,"Payment Schedule,"and Exhibit C,"Fee
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 fiords during the duration of this Agreement.
Island Grove,in accordance with federal HIPAA regulations,will be adopting the standard
transaction code set for all treatment services on or before October 16,2003. Even though this
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 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.
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Contract Number 03-CPS-25
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 chall
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. PaymentMethod
Unless otherwise provided in the Scope of Services and Payment Schedule:
a. Island Grove shall provide pioper 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 D,which is attached hereto and
incorporated herein by reference.
7. (ern 1plianre with Az plicable T?a
At all times during the performance of this contract,Island Grove chap 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 iecords,
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
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)
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Contract Number 03-CPS-25
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 by Island Grove and Social Services. The results of the monitoring and
evaluation shall be provided to the Board of Weld County Commissioners 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:
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 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 Island Groves 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.
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Contract Number 03-CPS-25
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 Island Grove:
B J Dean Executive Director,island Grove
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 I Dean,Executive Director
P D Box A 1 140 M Street
Greeley,CO RUM? Greeley,CO 50611
14. J.itigptinn
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.
16. Fntire 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 Number 03-CPS-25
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,month,and year first
above written.
ATTEST: —sfible#41“
WELD COUNTY BOARD OF COUNTY
CLERK TO THE BOARD COMMISSIONERS WELD
' COUNTY, RADO
By: 7ls ► /r7 � By.
Deputy Clerk , 186 �1;�`� '•fito�1 David E.Long,Char Q
O AST• 1O �, ISLAND GROVE
icy �_�ln-���►��.�- BY ueaSJ
County Att. � � B.J. Executive Director
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
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Contract Number 03-CPS-25
EXHIBIT A
SCOPE OF SERVICES
This service is for Social Services clients to complete up to seven days of monitored sobriety when referred by a
caseworker,or the court.Clients that are in need of additional sobriety monitoring are to be referred through the
Social Services Core Services process,and will not be reimbursed under this Agreement. Island Grove agrees to
follow the referral and payment procedures identified by Social Services.
Immediate Referral UA/Breathalyzer Testing
The 7-Panel baseline urinalysis test for alcohol and drugs screens for the following:
Tests determine what drugs are present in client.
THC Cutoff Level:50 ng/ml Amphetamines Cutoff Level: 1000 bg/ml
Cocaine Cutoff Level:300 ng/ml Barbiturates Cutoff Level:200 ng/ml
Benzodiazepines Cutoff Level:200 ng/ml Opiates Cutoff Level: 200 ng/ml
Creatinine >20 mgDL is normal 3-Panel Amphetamines,THC,
Cocaine
Other Services
Breathalyzer Testing $2.00/test
Urinalysis Testing(7-Panel) $25.00/test
Urinalysis Testing(3-Panel) $20.00/test
UA Confirmation(GCMS) $35.00
Immediate Patch Testing
The Patch test for alcohol and drugs screens for the following:
Tests determine what drugs are present in client.Patches are limited to one patch per week per client.Patch
services include confirmation of patch.The cost is$50 per patch application.
Test Methods and Detection Levels
Drug or Drug Class Method Cutoff Confirmation Method Test Cutoff
Amphetamine EIA 10 ng/ml GC/MS 10 ng ml n
Cannabis EIA 1.5 ng/ml GC/MS 9.5 ng ml
Cocaine EIA 10 ng/ml GC/MS l0 ng ml n
Opiates EIA 10 ng/ml GC/MS lOngmln
ng ml n
Phencyclidine EIA 7.5 ng/ml GC/MS 7.5 ng ml
Drug or Drug Class Test Result
Analyte
Amphetamine Negative
Cannabis Negative
Cocaine Negative
Opiates Negative
Phencyclidine Negative
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Contract Number 03-CPS-25
EaHUBIT B
PAYMENT SCHEDULE
1. Fib 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 Five Thousand Dollars($5,000.00)under Child Welfare Regular Administration
fimding.
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 far Servicee—as shown on the attached Exhibit C"Fee Schedule."
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.
3. Snhmittal of Vonehns
Island Grove shall prepare and submit monthly the itemized voucher according to the criteria listed under
"Standards of Responsibility"in Exhibit E,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 03-CPS-25
EXHIBIT C
Child Welfare Regular Administration Funds
Fee Schedule-2003-2004
Fees for Services under Immediate Referrals for Monitored Sobriety
Breathalyzer Testing $ 2.00/test
Urinalysis Testing(7-Panel) $25.00/test
Urinalysis Testing(3-Panel) $20.00/test
UA Confirmation(GCMS) $35.00
Patch Monitoring (Includes Confirmation) $50.00/each patch(limit of one patch per week)
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Contract Number 03-CPS-25
EXHIBIT D
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-contracted
providers 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
4o allow authorized local,Federal,and State auditors,and representatives to audit and monitor Island
Grove.
9. All such records,documents,comnnmications,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,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 Number 03-CPS-25
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. Me not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transaction by a federal department of agency.
b. Have not,within a three-year period of preceding this Agreement,been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining,attempting to obtain,or performing a public(federal,state,or local)transaction or
contract under a public transaction;violation of federal or state antitrust statutes or commission of
embezzlement,theft,forgery,bribery,falsification or destruction of records,making false
statements,or receiving stolen property;
c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(federal,state,or local)with commission of any of the offenses enumerated in paragraph 11(b)of
this certification;and
d. Have not within a three-year period preceding this Contract,had one or more public transactions
(federal,state,and local)terminated for cause or default.
15. The Appearance of Conflict of Interest applies to the relationship of a contractor with Social Services when
the contractor also maintains a relationship with a third party and the two relationships are in opposition. In
order to create the appearance of a conflict of interest,it is not necessary for the contractor to gain from
knowledge of these opposing interests. It is only necessary that the contractor know that the two
relationships are in opposition.During the term of the Contract,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 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
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Contract Number 03-CPS-25
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.
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Contract Number 03-CPS-25
EXHIBIT E
CHILD WELFARE REGULAR ADMINISTRATION FUNDS
Standards of Responsibility-
Island Grove agrees to:
1. Provide a written report to the Social Services caseworker within 24 hours of providing services to the
client;
2. Report to Social Services a monthly brief report on the status of the program as prescribed by Social
Services;
3. Report expenditures and case disbursement at agreed upon times.
4. Submit monthly-completed billing forms to Ms. Elaine Furister, CPS/CAP,Core Services Specialist,within
twenty-five(25)calendar days of the month following service in order to receive payment.Failure to submit
in a timely and complete manner shall result in forfeiture of payment.
5. In the event no service fees are incurred during the service month,an Authorization for Contractual
Services stating no services were provided for that service month shall be submitted within twenty-five(25)
calendar days following the month of service.
6. The provider shall submit an original Request for Reimbursement in complete form to re-bill for services
previously denied by the Department.If in the resolution process,the provider will not re-bill for payment
unless the provider can justify payment by documentation. The Department will not consider payments that
were originally reviewed as deficient in documentation without new documentation to justify payment.The
Department shall receive the Request for Reimbursement no later than five business days from receipt of a
certified letter from the Department documenting such denials of payment.
7. Work with family to prepare to pay for services beyond established time frame.
A complete and timely billing form is identified by and must include the following elements.
a. The billing must be an original billing signed by the provider and/or designee.
b. The billing must include all forms designed for Child Welfare Administration funding
reimbursement and approved by the Department of Social Services including Colorado State
Department of Social Services Authorization for Contractual Services form and Weld County
Monthly Request for Reimbursement under Child Welfare Regular Administration Funding.
c. A re-bill must include all forms designed for re-billing of Requests for Reimbursement under
Child Welfare Regular Administration funds,and approved by the Department of Social
Services.This includes a signed original Authorization for Contractual Services and Weld
County Program Re-bill under Child Welfare Regular Administration funds and Additional
Request for Reimbursement form.
1). Authorization for Contractual Services forms must be submitted completely filled in
with an original signature from the provider and/or designee.
2). Request for Reimbursement forms must include the client's full name;Weld County
household number,suffix number,and referral number,if applicable;units provided,
service date,unit rate,and total billed for the service date.
3). Requests for payment must be date stamped by the Department of Social Services by
the 25th day of the month following the service month.Requests for payment
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Contract Number 03-CPS-25
received after the 25th of the month following service will not be honored.
4). Re-bills for services must include only those items Island Grove can justify with
documentation and include a signed original Authorization for Contractual Services
form and Weld County Program Re-bill under Child Welfare Regular Administration
funds and Additional Request for Reimbursement form.The Weld County Rebill
under Child Welfare Regular Administration funding form must include the client's
name;household number and suffix number,if applicable;month of billed service,
re-bill amount,the approved entry date and exit dates,the actual units re-billed,the
rate per unit,and the re-bill total for the line item.
8. 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;
9. 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;
10. Be available to meet with DSS staff to explain program,time lines of response to referrals
and answer questions to enhance program.
11. Be available for the Families,Youth and Children Commission review and attendance at
the FYC meetings.
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Contract Number 03-CPS-25
5310.213(2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
1. WPM COI INTY 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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Contract Number 03-CPS-25
WELD COUNTY MONTHLY REQUEST FOR REIMBURSEMENT UNDER CHILD WELARE REGULAR ADMINISTRATION FUNDING
Remit to:Elaine Furister,CPS/CAP,Core Services Specialist
Name of Program Month of Service Weld County Department of Social Services
Notice to Providers:List all clients currently enrolled in your program. P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Enter 0 if no services were provided during billing month Telephone:970.352.1551,extension 6295
FAX:970.346.7698
Client Name HH# Referral# Approved Approved Date of Actual Rate per Total Payment Social Services Payments Services
(If Entry Exit Date Service Hrs/Units Unit Requested Only-Comments Denied/Delayed Payable
avplicable) Date
Social Service Codes:CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMIT-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
Page 15 of 16
Contract Nltrnber 03-CPS-25
WELD COUNTY RE-BILL UNDER CHILD'WELFARE REGULAR ADMINISTRATION FUNDS AND ADDITIONAL REQUEST FOR REIMBURSEMENT
Remit to:Elaine Furister,CPS/CAP,Core Services Specialist
Name of Program = Month of Service Weld County Department of Social Services
P.O.Box A,315 B N II Avenue,Greeley,CO 80632
Telephone:970.352.1551,extension 6295 FAX:970.346.7698
Client Name HH#&Client Referral# Month of Re-bill Approved Approved Actual Rate per Re-bill Certified Letter and (DSS Only)
Suffix Service amount Entry Date Exit Date Hrs/Units Unit Total Documentation Payable or
(Example: Re-billed Attached Not payable
11111-02)
(Include reason if not payable)
Social Service Codes:CE-Computation Error;NR-No Referral;BED-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
Page 16 of 16
l
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
Vi
GREELEY,CO 80632
WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
COLORADO
•
MEMORANDUM
TO: David E. Long, Chair Date: June 30, 2003
Board of County Commissioners I /y
FR: Judy A. Griego, Director, Social Services / VI fit
RE: Child Protection Agreement for Services Between 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). The Agreement was discussed and reviewed at the Board's Work Session
of June 23, 2003.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is July 1, 2003 through June 30, 2004.
2. The source of funding is Child Welfare Administrative Funds.
3. The Department agrees to reimburse Island Grove a maximum of$5,000, according to
the service and fee schedule provided by Island Grove.
4. Island Grove will provide immediate alcohol and drug testing of adults under the child
welfare system.
If you have any questions,please telephone me at extension 6510.
2003-1717
Hello