HomeMy WebLinkAbout20031328.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, 2003, and ending May 31, 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 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 28th day of May, A.D., 2003.
BOARD OF COUNTY COMMISSIONERS
WECOUNTY, COLORADO
ATTEST: ` J1
vid E , Chair
Weld County Clerk to, he BoatdF':' '
RobM11Lm
,
BY: O ' ` '
Deputy Clerk to the Boartq
M. J. eile
APPR AST •
Willi H. Jerk
ounty At or ey
Glenn Vaad 6L-4 es?
Date of signature:
/
2003-1328
L'L' SSiq? cQ2[q,) SS0030
Q
Contract No.FY 03-12000
CHILD PROTECTION XGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND NORTH RANGE BEHAVIORAL HEALTH
This Agreement,made and entered into the,L2 day of May 2003,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 Behavioral Health."
WITNESSETH
WHEREAS,required approval,clearance,and coordination have been accomplished from and with
appropriate agencies;and
rJ
WHEREAS,the Colorado Department of Human Services has provided Core Services Colorado Fami%!
Preservation Act Fund resources to Social Services for psychological evaluation and assessment services for -
families, children,and adolescents;and
WHEREAS,North Range Behavioral Health is the Mental Health Assessment and Services Agency far
Weld County and has the expertise and ability to provide psychological and assessment services.
NOW THEREFORE,in consideration of the premises,the parties hereto covenant and agree as folloW9
w
1. Term
This Agreement shall become effective on June 1,2003,upon proper execution of this Agreement and shall
expire May 31,2004.
2. Scope of Services
Services shall be provided by North Range Behavioral Health 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,"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 Behavioral Health 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.
Failure to submit monthly billings in accordance with the terms of this agreement shall result in
North Range Behavioral Health forfeiture of all rights to be reimbursed for such expenses. In the
event of a forfeiture of reimbursement,North Range Behavioral Health 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.
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Contract No.FY 03-12000
• 4. Financial Management
At all times from the effective date of this Contract until completion of this Contract,North Range
Behavioral Health 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 Services and the Family and Children's
Program 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health acknowledges that
the following laws are included:
Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d-I et. Seq. and its implementing
regulation,45 C.F.R.Part 80 et. Seq.; and
Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794,and its implementing
regulation,45 C.F.R. Part 84;and
the Age Discrimination Act of 1975,42 U.S.C. Sections 6101 et seq. and its implementation
regulation,45 C.F.R. Part 91;and
Title VII of the civil Rights Act of 1964; and
- the Age Discrimination in Employment Act of 1967;and
the Equal Pay Act of 1963;and
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
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Contract No.FY 03-12000
North Range Behavioral Health 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 Behavioral Health and Social Services agree that monitoring and evaluation of the
performance of this Agreement shall be conducted by North Range Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health. These remedial actions are as follows:
a. Withhold payment to North Range Behavioral Health 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 Behavioral Health 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 North Range Behavioral Health 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 Behavioral Health,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 Behavioral Health:
Wayne Maxwell,Executive Director North Range Behavioral Health
Name Title
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Contract No.FY 03-12000
• 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 Behavioral Health
Judy A.Griego,Director Wayne Maxwell,Executive Director
P.O. Box A 1306 11`s Avenue
Greeley,CO 80631 Greeley,CO 80631
14. Litigation
North Range Behavioral Health shall promptly notify Social Services in the event that North Range
Behavioral Health learns of any actual litigation in which it is a party defendant in a case that involves
services provided under this Agreement. North Range Behavioral Health,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.
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 written.
ATTEST:
I
WELD COUNTY ' P •F COUNTY COMMISSIONERS
CLERK TO THE BOA 961 AUNTY, OLO' 'O
By:
•p avid.Long, .it N"
Deputy Clerk ti` ��}> ; '1\
APPROVED AS TO FORM:
Co$' ` p_
Co ty A . ey
WELD COUNTY DEPARTMENT NORTH RANGE BEHAVIORAL HEALTH
OF SOCIAL SERVICES By: \ t i By: 6 I are /22� el
Dir jrWayne M xwell
Executive Director
too a—)Milet)
Board Chairperson
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Contract No.FY 03-12000
EXHIBIT A
SCOPE OF SERVICES
1. Target/Eligible Population
The population to be served under this contract includes non-Medicaid eligible abused and neglected
children who are at risk of out-of-home placement,who are clients of Social Services,and are in need of
North Range Behavioral Health's 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 include the following:
a. Family/Child/Adolescent Psychological Evaluation/Assessment Services
Families,children and adolescents who are eligible and in need will be provided screening,
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 contacts
that need to be made prior to the completion of the evaluation.
North Range Behavioral Health will provide Social Services a written report upon completion of
the assessment that clearly states methods used,contacts made,tests administered,results,and
recommendations relevant to the referral questions.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.
b. Consultation
A licensed or licensed eligible psychologist of North Range Behavioral Health will be available to
directly consult with caseworkers of the Social Services regarding the integration of assessment
results into the overall care plans for children,adolescents, and families.This may include issues
pertaining to the evaluation of suicidal clients and the need for inpatient placement or other levels
of intervention.The licensed or licensed eligible psychologist would be available to assist in
obtaining written feedback from North Range Behavioral Health clinicians regarding the rationale
for decision on these issues.
c. Court Testimony
The licensed or licensed eligible psychologist providing the above services will be available for
court testimony when given proper notification.North Range Behavioral Health will provide court
testimony for clients who were provided psychological evaluation and assessment services by
North Range Behavioral Health and who have either open or closed cases.
3. Service Time Frames
The turn-around time on evaluations will be no more than forty-five(45)days from the point of referral.
Consultation services will be as needed to the fullest extent possible,as capacity allows.
4. Measurable Outcomes
This design will shorten the time required to obtain evaluation results following a Social Service referral.
The services provided by this contract will also increase the Social Service staff access to the evaluation
*An academically qualified,(post doctorate)candidate for licensure under the constant direct supervision of a
licensed clinical psychologist.
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Contract No.FY 03-12000
practitioner when questions about implementation of evaluation results occur. A greater frequency of
contacts between the evaluation practitioner and the Social Service staff will occur. Faster and more timely
responses from the Children and Family Services Outpatient Program of North Range Behavioral Health
will occur and therapeutic interventions will be better coordinated between agencies. All of these outcomes
can be quantified and compared with status prior to the implementation of the contract. The Directors of
the Social Services and North Range Behavioral Health shall jointly assign measures that will serve as
specific outcome targets.
Emergency consultations will occur within twenty-four(24)hours of request.
All psychological evaluations will have clear recommendations and methods that will be
accepted by the court.
Five(5)to six(6)assessments will be accomplished each month.
5. Workload Standards
Five(5)to six(6)assessments of varying types will be accomplished each month,as dictated by demand.
6. Staff Qualifications
The North Range Behavioral Health staff performing these assessments will be a licensed or licensed
eligible psychologist with appropriate training and expertise with formal evaluation techniques.
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Contract No.FY 03-12000
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to North Range Behavioral Health in consideration for the work and
services performed a total not to exceed Ninety-Seven,Five Hundred Forty-four Thousand($97,544.00)
under Child Welfare Services and Family and Children's Program Funding.
Expenses incurred by North Range Behavioral Health,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 Colorado Family Preservation Act funds,whether in whole or in part,
is subject to and contingent upon the continuing availability of Colorado Family Preservation Act funds for
the purpose hereof.In the event that said funds or any part thereof,become unavailable as determined by
Social Services, Social Services may immediately terminate this Contract or amend it accordingly.
2. Fees for Services
For psychological evaluation and caseworker consultation services only, Social Services agrees to pay
North Range Behavioral Health for the costs of services at an hourly rate of$83.20 not to exceed Ninety-
seven Thousand,Five Hundred,Forty-four dollars($97,544.00)during FY 2003-2004.
3. Standards of Responsibility
The Contactor agrees to:
A. Provide a case management plan on each referred family within 30 days of the date the
Contractor received the referral.The case management plan will be monitored and modified
monthly to measure progress toward goals. Copies of the case management plan must be sent to
the caseworker,program area supervisor, and Ms. Elaine Punster, CPS/CAP,Core Services
Specialist, at Weld County Department of Social Services,P.O.Box A,315 B N I 1 Avenue,
Greeley, Colorado, 80632. The case management plan will include at a minimum goals,
timelines,and measurement of success.
B. Provide a monthly client progress report as above within twenty-five working days immediately
after the month of service.The monthly progress report must be attached to the monthly billing
for payment to be honored.Failure to submit such monthly reports will result in delays or
forfeiture of payment.
Monthly Reports-will be submitted no later than twenty-five(25)working days past the
end of the month of service. It is expected,at a minimum,that these reports will reflect:
-presenting problem(s)of the client/family,
-specific services provided,
-extent of client(s)participation and commitment to program,
-client(s)progress to date,
-anticipated discharge date.
C. Report to Social Services a monthly brief report on the status of the program as prescribed by
Social Services;
D. Submit a final narrative summary of program outcomes to Social Services within 30 days after
the completion date;
E. Report expenditures and case disbursement at agreed upon times;
F. Submit monthly FYC completed billing forms,as identified in attached Exhibit D,"Special
Conditions,"to Ms. Elaine Furister,CPS/CAP,Core Services Specialist,within twenty-five(25)
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Contract No.FY 03-12000
calendar days of the month following service in order to receive payment,subject to future
modification as prescribed by CYF(Children,Youth,and Families)automation when
implemented.Failure to submit in a timely and complete manner shall result in forfeiture of
payment.
G. 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.
H. The Contractor shall submit an original Request for Reimbursement in complete form to re-bill
for services previously denied by Social Services.If in the resolution process,the provider will
not re-bill for payment unless the provider can justify payment by documentation. Social
Services will not consider payments that were originally reviewed as deficient in documentation
without new documentation to justify payment. Social Services shall receive the Request for
Reimbursement no later than five business days from receipt of a certified letter from Social
Services documenting such denials of payment.
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.
1. The billing must be an original billing signed by the provider and/or designee.
2. The billing must include all forms designed for Core Services reimbursement and
approved by Social Services;Core Services Authorization of Funds,Project Report,
Update Report,and signed client verifications for each client serviced during the billing
period.
3. A re-bill must include all forms designed for re-billing of Core Service Requests for
Reimbursement and approved by Social Services.This includes a signed original
Authorization for Contractual Services and Weld County Core Services Program Re-bill
and Additional Request for Reimbursement form.
4. Each client who has a current referral,both receiving services and not receiving services
during the service month,must be listed on the billing form.A service summary must be
provided by the provider for clients who have active referrals during the billing month in
order to direct issues to the caseworker and court.
a) Core Services Authorization forms must be submitted completely filled in with an
original signature from the Contractor and/or designee.
b) Project reports must include the client's full name,Weld County household
number, suffix number,referral number,hours served,hourly rate,and total billed
for the month the service was provided.
c) Verification forms must include the client's original signature at the time of
service,date of service,hours served,client's household number and Core service
referral number.Payment through Core Services Program funds will be made only
for direct client contact with the appropriate identifying client signature included
on the verification form
d) Requests for payment must be date stamped by Social Services by the 25th day of
the month following the service month.Requests for payment received after the
25th of the month following service will not be honored.
e) Re-bills for services must include only those items the provider can justify with
documentation and include a signed original Authorization for Contractual
Services form.The Weld County Core Services Program Re-bill and Additional
Request for Reimbursement form must include the client's name,household
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Contract No.FY 03-12000
number,suffix number,month of billed service,re-bill amount,the approved entry
date and exit dates,the actual hours re-billed,the rate per unit, and the re-bill total
for the line item.
J. 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;
K. 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;
L. Be available to meet with DSS staff to explain program,time lines of response to referrals and
answer questions to enhance program.
M. Be available for the Families,Youth and Children Commission review and attendance at the FYC
meeting.
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Contract No.FY 03-12000
EXHIBIT C
ASSURANCES
1. North Range Behavioral Health 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 Behavioral
Health or its employees,volunteers,or agents while performing duties as described in this Agreement.
North Range Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health.
9. All such records, documents,communications,and other materials shall be the property of Social Services
and shall be maintained by North Range Behavioral Health,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 Behavioral Health 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 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.
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Contract No.FY 03-12000
11. This Contract shall be binding upon the parties hereto,their successors,heirs,legal representatives,and
assigns. North Range Behavioral Health or Social Services may not assign any of its rights or obligations
hereunder without the prior written consent of both parties.
12. North Range Behavioral Health certifies that Federal appropriated funds have not been paid or will be paid,
by or on behalf of North Range Behavioral Health,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 Behavioral Health 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 Behavioral
Health understands that the source of funds to be used under this Contract is: Family Issues Cash Funds.
14. North Range Behavioral Health 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
judgement 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health 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 Behavioral Health.
16. North Range Behavioral Health 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 Behavioral Health shall be disclosed in a form identifiable with the
applicant/recipient or a minor's parent or guardian. North Range Behavioral Health shall have written
policies governing access to,duplication and dissemination of,all such information. North Range
Behavioral Health 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.
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Contract No.FY 03-12000
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 Behavioral Health in the course of providing services under
this Contract will be accorded at least the same precautions as are employed by North Range Behavioral
Health for similar information in the course of its own business.
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Contract No.FY 03-12000
EXHIBIT D
SPECIAL CONDITIONS
A. Reimbursement for the Unit of Services will be based on an hourly rate per child or per family.
B. The hourly rate will be paid for only direct face-to-face contact with the child and/or family,as
evidenced by client-signed verification form.
C. Unit of service costs cannot exceed the hourly,and yearly cost per child and/or family.
D. Rates will only be remitted on cases open with,and referrals made by Social Services.
E. Requests for payment must be an original and submitted to Social Services by the end of the 25th
calendar day following the end of the month of service.The provider must submit requests for
payment on forms,as identified in Exhibit D,and as approved by Social Services.
F. Requests for payment must include original client verification signatures(blue or red ink preferred)
and dates and hours of service.
Page 13 of 18
Contract No.FY 03-12000
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.
Page 14 of 18
•
Contract No.FY 03-12000
WELD COUNTY CORE SERVICES PROGRAM MONTHLY REQUEST FOR REIMBURSEMENT
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 II 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#&Client Referral# Approved Approved Actual Maximum Hours Rate per Monthly Social Services Only- Payments Services
Suffix Entry Date Exit Date Hrs/Service Sessions/ Unit Total Comments Denied/Delayed Payable
(Example: Period Service
11111-02) Period
•
Social Service Codes:CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMH-Exceeds Maximum Hours;EMS-Exceeds Maximum Sessions;NP-Not Payable;PD-Payment Delayed;SPD;
Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;PR-Progress Report Needed
Page 15 of 18
•
Contract No.FY 03-12000
WELD COUNTY CORE SERVICES PROGRAM PROJECT REPORT .
Remit to:Elaine Furister, CPS/CAP,Core Services Specialist
Weld County Department of Social Services
Program Month of Service P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Telephone:970.352.1551,Ext.6295 FAX:970.346.7698
#Households Referred During #of Households Enrolled #of Households Served During #of Households Discharged Monthly Expenditure Expenditures to Date
Month During Month Month During Month
Termination Reason Codes:SEP-Successfully Ended Program;M-Moved;UL-Unable to Locate;RCCF-Entered a Residential Facility;FCR-Foster Care Review;OT-Explain,TM-Transferred to Another Program
More Restrictive;FC-Entered Foster Care;NT-Terminated;Unable to Work with Client;RH-Returning to Relative
Child's Name Direct Service Date Service Termination Client Caseworker Provider Initial Case Monthly Progress Funding Total Cost Social Services
Date Ended Reasons Survey Survey Survey Management Report Source of Program Use
i Plan(Date) to Date
Funding Source:EPP-Expedited Permanency Planning;M-Medicaid;CI-Client Insurance;O-Other
Page 16 of 18
Contract No.FY 03-12000
CORE SERVICES PROGRAM YEAR 2003-2004-CLIENT VERIFICATION FORM
Notice to Provider:This verification form must be completed at the time of service by all clients served during the service month.No request for payment of services will be honored for billed services unless accompanied by
the appropriate signed client verification form.Payment for services will not exceed maximum hours or sessions as stated in provider's RFP.
Section I: (To be completed by the provider)
Primary Client billed: Total Hours Billed
Household Number: Referral Number: Contact Person:
SECTION II(To be completed by client)
Client signatures must be signed at the time of service.Your signature verifies that services were provided by the service provider for direct face-to-face contact only,for the hours indicated.
Date Hours Number of Hours of Client/Participant Signature(Please have all those attending sign.In the case of a child who is not able to sign,please have someone sign for
Please state hours of Service Provided the child;i.e.,Sally Smith by Gregg Jones,Foster Parent
services;i.e.,
1:00—2:30
Notice to Provider:Attach all client verification forms to the monthly billing when submitting your request for Payment for Contractual Services.All Requests for payment must be received by the 25s'day of the month
following service in complete form.Send original signed billing and verifications to:Elaine Furister,CPS,Core Service Specialist,Weld County Department of Social Services
P.O.Box A,315 B N 11 Avenue,Greeley,CO,80632
Telephone:970.352.1551,extension 6295;FAX.346.7698
Page 17 of 18
Contract No.FY 03-12000
•
WELD COUNTY CORE SERVICES PROGRAM RE-BILL 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
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#&Client Referral# Month of Re-bill Approved Approved I Actual Rate per ' Re-bill Certified Letter and (DSS Only)
Suffix Service amount Entry Date Exit Date firs/ Unit Total Documentation Payable or
(Example: Re-billed Attached Not payable
11111-02) (Include mason if not payable)
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
Page 18 of 18
w
DEPARTMENT OF SOCIAL SERVICES
f P.O. BOX A
GREELEY,CO. 80632
' Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO MEMORANDUM
TO: David E. Long, Chair Date: May 21, 2003
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services C
RE: Child Protection Agreement for Services Betwe n 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. The
Agreement was discussed and reviewed at the Board's Work Session of May 12, 2003.
The major provisions of the Agreement are as follows:
1. The term of the Agreement is June 1,2003 through May 31, 2004.
2. The source of funding is Core Services Funding. The maximum funding level under the
Agreement is $97,544 and at an hourly rate of$83.20.
3. North Range Behavioral Health will provide:
A. Psychological evaluations and assessment services for families, children,and
adolescents who are non-Medicaid eligible,but who require child welfare
services; and
B. Consultation services,through a licensed or licensed eligible psychologist, for
case workers regarding the integration of assessment results into overall care
plans; and
C. Court testimony for clients who were provided services under the Agreement and
have either open or closed cases.
If you have any questions,please telephone me at extension 6510.
2003-1328
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