HomeMy WebLinkAbout20031720.tiff RESOLUTION
RE: APPROVE 20 AGREEMENTS TO PURCHASE RESIDENTIAL TREATMENT
CENTER SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO
SIGN
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 20 Agreements to Purchase Residential
Treatment Center 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 the following providers, commencing July 1, 2003, and ending June 30, 2004, with
further terms and conditions being as stated in said agreement, and
1) Courthouse, Inc. - Marilee Center
2) Courthouse, Inc. - Daybreak - Princeton
3) Devereux Cleo Wallace - Colorado Springs
4) Devereux Cleo Wallace -Westminiister
5) El Pueblo Boys and Girls Ranch
6) Monarch Youth - Blue Mountain Ranch
7) Monarch Youth - Wilderness Treatment Center
8) Monarch Youth - Prairie View Treatment Center
9) Monarch Youth - Byron Grizmore Treatment Center
10) Monarch Youth - Fox Drive Treatment Center
11) Shiloh Homes - Shiloh House Estes
12) Shiloh Homes - Denver
13) Shiloh Homes - Shiloh House Portland
14) Shiloh Homes - Shiloh House Sheridan
15) Shiloh Homes - Shiloh House Yarrow
16) Shiloh Homes - Craig
17) The Mountain Star Center
18) Third Way Center- York
19) Third Way Center- Pontiac
20) Third Way Center- Lincoln
WHEREAS, after review, the Board deems it advisable to approve said agreements,
copies of which are 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 Nine Agreements to
Purchase Child Placement Agency 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 the above listed providers be, and hereby are, approved.
2003-1720
&O ; �S Co? 9) SS0030
RESIDENTIAL TREATMENT CENTER AGREEMENTS
PAGE 2
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said agreements.
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 D OF COUNTY COMMISSIONERS
WE COU TY, COLORADO
ATTEST: gullG';.'< ,,
',a vid E. Long, Chair
Weld County Clerk tp/the ,
Robert D. sden, Pro-T m
Deputy Clerk to th y NI
M. J. eile
ADO DASTc�y{��• 11,1-7S1/‘ C
.� Willi�yq H. Jerke
unty Attorney) 44.10/\
/ Glenn Vaa
Date of signature: //d
2003-1720
SS0030
• , Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this day of;f{ig 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social Setices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Courthouse Inc., 333 W
Hampden Ave, Suite 305, Englewood, CO 80111-2333, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$27.22 per day for children placed within
the Residential Treatment Center identified as Provider ID#45724. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 45724
Marilee Center
3864 W Princeton Ct
Denver CO 80236
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which maybe amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which maybe
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system,which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department(Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
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Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living O Other(Specify)
S. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family O Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST:
Weld Co ty Clerk to the o8rd
Fria 1i�► BOARD OF SOCIAL SERVICES,EHALF OF THE
RTMENT OF SOCIAL SERVICES
. 1861 jO �q� .
By. By
► puty Clerk t l�~��" 7/ David .Long, it I I n
/ `/' 'VW V 2 2003
APPROVED AS TO FO `
��-- CONTRACTOR
County Attorney
Courthouse Inc.
333 W Hampden Ave, Suite 305
Englewood, CO 80111-2333
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
irector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this o! day ofjelci 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social Sices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Courthouse Inc., 333 W
Hampden Ave, Suite 305, Englewood, CO 80110-2333, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$27.22 per day for children placed within
the Residential Treatment Center identified as Provider ID#46050. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services
Contract No: 1W 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include,but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 46050
Daybreak- Princeton
3640 W Princeton Ave
Denver CO 80236-2333
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15`h and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: FY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care O Shelter Care ❑ Substance Abuse Treatment
O CORE Services O Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care O Group Home O Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family O Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior O Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first
t_above
/written.
ATTEST: f��'r''''r'1 ��"t/"
Weld County Clerk to the Board
�.;LEce BOARD OF SOCIAL SERVICES,
I BEHALF OF THE
TMENT OF SOCIAL SERVICES
.. 1 1661 "`
- By:
�
• �!'
puty Clerk t avid E.Long, it JUL 0 2 M
APPROVED AS TO FO
CONTRACTOR
ounty ttorne
Courthouse Inc.
333 W Hampden Ave, Suite 305
Englewood,, CO 80110-2333
By: ale n�..-'.,-74,4 "/LI
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Directo
12
Agreement to Purchase
•
RTC Services
• , Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
nd
THIS AGREEMENT made this(7(
--day of___ 2003 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 called "County" and Devereux Cleo Wallace, 7100 E
Belleview Ave, Suite 210, Englewood, CO 80111, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.74 per day for children placed within
the Residential Treatment Center identified as Provider ID#39796. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement maybe renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services moos _-/7 ?
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
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Agreement to Purchase
RTC Services
• . Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 39796
Devereux Cleo Wallace
430 Gold Pass Heights
Colorado Springs CO 80906
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
• . Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
' , Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
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Agreement to Purchase
RTC Services
' Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
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Agreement to Purchase
RTC Services
' . Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
' Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system,which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15`h and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
' ,Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
' Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case,which involves
services provided under the agreement. The Contractor,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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract Nn: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services El Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC O Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home O Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: 414/11/1/a%
Weld County Clerk to the Board
i:.O Z BOARD OF SOCIAL SERVICES,
'EHALF OF THE
TMENTOF SOCIAL S CES
1851
By.
eputy Clerk t . a`- , David E. Long,Cri JUL 0 2 2003
APPROVED AS TO FORM:`-
CONTRACTOR
County At me
Devereux Cleo Wallace
7100 E Belleview Ave, Suite 210
Englewood:TO 80111
By: ( Z-K)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ector
12
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
Ad
THIS AGREEMENT made this day of-114, 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social S&vices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Devereux Cleo Wallace, 7100 E
Belleview Ave, Suite 210, Englewood, CO 80111, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.74 per day for children placed within
the Residential Treatment Center identified as Provider ID#39794. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
i
Agreement to Purchase
RTC Services -d' cO 3-/7c70
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 39794
Devereux Cleo Wallace
8405 Church Ranch Blvd
Westminster, CO 80021
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts,whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff Reimbursement for placement services shall be paid from the
date of admission up to,but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator)within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4)months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department(Field Audits) for approval within four(4)months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
O Placed through a Voluntary Placement Contract signed by(Fill in Name).
O Placed through court order and legal custody/guardianship is held by Weld County DSS.
O Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? 0 Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
O In home services 0 Placement with Relative ❑ Cty CC Foster Care 0 Shelter Care 0 Substance Abuse Treatment
❑ CORE Services 0 Receiving Home 0 CPA 0 RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) 0 Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family 0 Group
Appropriate Treatment:
O Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse 0 Truancy 0 Victim Behavior ❑ Depression
❑ Self-destructive 0 Delinquency ❑ Special Medical Needs 0 Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. 0 Public School 0 Day Treatment
❑ On-grounds School 0 Additional Tutoring ❑ Independent Living Training 0 Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: MISS/
Weld County Clerk to the Board
BOARD OF SOCIAL SERVICES,
BEHALF OF THE
W' ' 't' `��' •RTMENT OF SOCIAL SERVICES
1861By:
.��
By:
�� y David E. Long, UL 0 2 2003
i epuTy Clerk t.( � ,A�+ � C it
APPROVED AS TO FO
CONTRACTOR
County ey
Devereux Cleo Wallace
7100 E Belleview Ave, Suite 210
Englewood,
{CCO`/80111 By:WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
12
Agreement to Purchase
RTC Services
', Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this day of Jilt, 2003 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 called "County" and El Pueblo Boys' and Girls'
Ranch, One El Pueblo Ranch Way, Pueblo, CO 81006,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$31.52 per day for children placed within
the Residential Treatment Center identified as Provider ID#45146. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services a7C63- 7.7
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 45146
El Pueblo Boys' and Girls'Ranch
1591 Taos Rd.
Pueblo CO 81006
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
ro
Agreement to Purchase
RTC Services
Cgntract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
El Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
El Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? El Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? El Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative El Cty CC Foster Care ❑ Shelter Care El Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home El CPA ❑ RTC ❑ Cty regular Foster Care
El Day Treatment El Kinship Care El Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
El Therapeutic(Behavior Modification) ❑ Secure El Other(Explain)
Appropriate Counseling:
El Individual ❑ Family ❑ Group
Appropriate Treatment:
El Sex Offender El AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior El Depression
El Self-destructive El Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
El Special Ed. El Public School ❑ Day Treatment
El On-grounds School ❑ Additional Tutoring ❑ Independent Living Training El Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
El It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) El Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: Midlamin
Weld County Clerk to the Board
IIE O�► Y BOARD OF SOCIAL SERVICES,
J BEHALF OF THE
W> `a t'i' =�r•RTMENT OF SOCIAL SE CES
J 1861 1 C7�/ � `
By:-... ;1 r�� By:
Deputy Clerk t�l?IO �• ,�'�,; avid E. Long,Chai JUL 0 2 2nn3
APPROVED AS TO FO "
CONTRACTOR
CountyAtto y
El Pueblo Boys' and Girls' Ranch
One El Pueblo Ranch Way
Pueblo, CO 81006
By: 2Q
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: VL
hector
12
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
41(1
THIS AGREEMENT made this c t day of , 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social S rvices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Monarch Youth, 2695 W
Eisenhower Blvd, Suite 208, Loveland, CO 80537-4339, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#38462. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record(CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
i
Agreement to Purchase
RTC Services ;.:;?Ae 3 -/7,7.O
'Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 38462
Blue Mountain Ranch
2100 Blue Mountain Dr
Berthoud CO 80513
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
• • Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department(Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4)months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
'Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ONo
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services 0 Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home 0 CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
O Therapeutic(Behavior Modification) ❑ Secure 0 Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family 0 Group
Appropriate Treatment:
O Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive 0 Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
O Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School 0 Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
' 'Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first a_ f �D�'booveewriittteen.n.
ATTEST: "' ' I/�G.re�i1(
Weld County Clerk to the Board
I,!1i*v1Fact n BOARD OF SOCIAL SERVICES,
BEHALF OF THE
TMENT OF SOCIAL SER ICES
r 1861 ( O1
y= ..
-Deputy Clerk t � David E. Long,C JUL 0 2 2003
APPROVED AS TO FOAAAVVV-
CONTRACTOR
unty Att mey
Monarch Youth
2695 W Eisenhower Blvd, Suite 208
Loveland, CO 80537-4339 By: ‘.‘1L.
�
N-
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this day ofllhj, 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social S rvices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Monarch Youth, 2695 W
Eisenhower Blvd, Suite 208, Loveland, CO 80537-4339, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#1500261. These services
will be for children who have been deemed eligible for social services under the statutes,
rules and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record(CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
i
Agreement to Purchase
RTC Services o7003 -/7aO
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 1500261
Fox Drive Treatment Center
3400 Fox Dr
Loveland CO 80537
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours,weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION IIL REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation maybe by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
a
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator)within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative O Cty CC Foster Care O Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent O Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
tin r
ATTEST: / '////�"�/!
Weld County Clerk to the Board
441 �BOARD OFF OCI L SERVICES,
EHALF OF THE
RTMENT OF SOCIAL SER ES
n1861 ��
B / i Sali� _sue By:
:eputy Clerk t k$o•rd ) d%" David E. Long, a r JUL 0 2 2003
APPROVED AS TO FORM:
CONTRACTOR
County Atto ey
Monarch Youth
2695 W Eisenhower Blvd, Suite 208
Loveland, CO 80537-4339
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
-id Id `
THIS AGREEMENT made thisr'day oflit, 2003 between the Board of Weld
County Commissioners, sitting as the Board of Socials rvices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Monarch Youth, 2695 W
Eisenhower Blvd, Suite 208, Loveland, CO 80537-4339, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#1503010. These services
will be for children who have been deemed eligible for social services under the statutes,
rules and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services a20(1.3`)7,2D
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 1503010
Byron Grizmore Treatment Center
204 WCR 10E
Berthoud CO 80513
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure,where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to,but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the l 5ch and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator)within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department(Field Audits) for approval
within four(4)months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any inununities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
Li In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above wrriittteen.n.
ATTEST: � rc¢ccf ,��//l/(.�il4
Weld County Clerk to the Board
Lac �- BOARD OF SOCIAL SERVICES,
•rBEHALF OF THE
W¢ r. RTMENT OF SOCIAL SERVICES
1861 �( `: .
r''. % �(
By: q BY
:eputy Clerk tai G,,: t c�, David E.Long, ha JUL 0 2 2003
APPROVED AS TO FORM':-- J
i
CONTRACTOR
County Atto ey
Monarch Youth
2695 W Eisenhower Blvd, Suite 208
Loveland, CO 805 7-4339
c
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
'rector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made thisor day ofj&Zit, 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social S rvices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Monarch Youth, 2695 W
Eisenhower Blvd, Suite 208, Loveland, CO 80537-4339, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#1510808. These services
will be for children who have been deemed eligible for social services under the statutes,
rules and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
i
Agreement to Purchase
RTC Services &DO.3 -/7„2
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include,but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 1510808
Prairie View Treatment Center
8233 E County Rd 18
Loveland CO 80537
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours,weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts,whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department(Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department(Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess,nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor,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, reorganizations and/or
foreclosure.
io
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care O Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home O Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first
above written.
! 'f-'4 Old ial%
ATTEST:
Weld County Clerk to the Board
BOARD OF SOCIAL SERVICES,
BEHALF OF THE
RTMENT OF SOCIAL SE CES
7 1861 ,r=:;.:tC°1, .-.i
By� By:
eputy Clerk t avid E.Long, it JUL 0 2 2003
APPROVED AS TO FO s
CONTRACTOR
ounty Atto ey
Monarch Youth
2695 W Eisenhower Blvd, Suite 208
Loveland, CO 80537-4339
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
hector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
JO.
THIS AGREEMENT made this,- day of Jj, 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social rvices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Monarch Youth, 2695 W
Eisenhower Blvd, Suite 208, Loveland, CO 80537-4339, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$41.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#1513874. These services
will be for children who have been deemed eligible for social services under the statutes,
rules and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, retum
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services a 063 -J707O
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 1513874
Wilderness Treatment Center
8335 Wilderness Dr
Colorado Springs CO 80908
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system,which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. hi cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4)months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No:•PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care
O CORE Services ❑ Substance Abuse Treatment
❑ Receiving Home O CPA ❑ RTC ❑ Cty regular Foster Care❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living
❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent O Substance Abuse ❑ Truanc
❑ o ❑ Victim Behavior ❑ Depression
rManagement
Self-destructive O Delinquency ❑ Special Medical Needs ❑ Behavior Modification
❑ O Anger
Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School ❑ Day Treatment
❑ On-grounds School O Additional Tutoring ❑ Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
��tt��
ATTEST: ���/�"v�Gn.�
Weld County Clerk to the Board
qt,f BOARD OF SOCIAL SERVICES,
J r BEHALF OF THE
W w _ RTMENT OF SOCIAL SE ES
1861 (r 4- ? -- .1
G/ w 7 11
By: C
puty Clerk t David E. Long,Ch r JUL 0 2 7nn1
Isk
APPROVED AS TO FO'
CONTRACTOR
3tomey
Monarch Youth
2695 W Eisenhower Blvd, Suite 208
Loveland, CO 80537-4339
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
rector
12
Agreement to Purchase
RTC Services
•
• -Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this y- day of 2003 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 called "County" and Shiloh Home, 6400 W Coal
Mine Ave, Littleton, CO 80123, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$34.13 per day for children placed within
the Residential Treatment Center identified as Provider ID#20335. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services oWQ3-/7aO
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 20335
Shiloh House Estes
7623 S Estes Ct
Littleton, CO 80128
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4)months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
' Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ONO
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment O Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above ve written.
ritee
�
ATTEST: �" i A2I
Weld County Clerk to the Board
OARD OF SOCIAL SERVICES,
EHALF OF THE
TMENT OF SOCIAL S VICES
1861
deputy Clerk to , (•` �+y, David E.Long, C it JUL 0 2 2003
U
APPROVED AS TO FORM: ,
� CONTRACTOR
County Atto y
Shiloh Home
6400 W Coal Mine Ave
Littleto , 3
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
irector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this::9--day of�[(Jy,, 2003 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 called "County" and Shiloh Home, 6400 W Coal
Mine Ave, Littleton, CO 80123, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$34.13 per day for children placed within
the Residential Treatment Center identified as Provider ID#32567. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services
003-�7�D
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 32567
Shiloh Home
3500 W 55th Ave
Denver, CO 80221
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which maybe amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department(Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment El Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) El Secure ❑Other(Explain)
Appropriate Counseling:
El Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification
❑ Other (Explain) ID Anger Management
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11.
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ten.
ATTEST: "1%4.4
Weld County to the d
BOARD OF SOCIAL SERVICES,
!�4 BEHALF OF THE
1 W i a Ni may RTMENT OF SOCIAL SERVICES
86
B
By Deputy Clerk t,7`$� Y• avid E.Long,Cha JUL 0 2 2003
a
APPROVED AS TO FORK:a—''i
CONTRACTOR
County tt ey
Shiloh Home
6400 W Coal Mine Ave
Littleto 3
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
'rector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this cday of 1.-tuyy, 2003 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 called "County" and Shiloh House, 6400 W Coal
Mine Ave, Littleton, CO 80123, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$34.13 per day for children placed within
the Residential Treatment Center identified as Provider ID#54169. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services 071123- /7,7
Contract No: PY 03/04-SS-23A-RTC
the thirty (30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 54169
Shiloh House Portland
6629 W Portland Ave
Littleton CO 80123
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which maybe amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
a
Agreement to Purchase
RTC Services
•
• Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
•
Contract No: -PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care O Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA O RTC O Cty regular Foster Care
O Day Treatment ❑ Kinship Care ❑ Group Home O Ind.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse O Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive O Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
O Special Ed. O Public School O Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ it has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: aGh an.
Weld County Clerk to the Board
1 la Y BOARD OF SOCIAL SERVICES,
BEHALF OF THE
W + +TMENT OF SOCIAL SERVICES
'/ , j•.
.'1861 (I ' .41/41y
B - By:
eputy Clerk ' + �xy/J' David E. Long, h
h JUL 0 2 2003
APPROVED AS TO FO .__ '-
rL\ CONTRACTOR
County Atto y
Shiloh House
6400 W Coal Mine Ave
Littleto , C( OT23�9-8
By: J
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
hector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
lI1a
THIS AGREEMENT made this d--day of cJQ2 2003 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 called "County" and Shiloh House, 6400 W Coal
Mine Ave, Littleton, CO 80123, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$34.13 per day for children placed within
the Residential Treatment Center identified as Provider ID#62291. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
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Agreement to Purchase
RTC Services 5e43-/lad
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Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include,but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 62291
Shiloh House Sheridan
7201 S Sheridan Ct
Littleton CO 80123
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
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Agreement to Purchase
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Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
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Agreement to Purchase
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Contract No: PY 03/04-SS-23A-RTC
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5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4)months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
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Agreement to Purchase
RTC Services
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Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
El Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? El Yes El No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? El Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
El In home services El Placement with Relative ❑ Cty CC Foster Care El Shelter Care
ment
El CORE Services ❑ Receiving Home ❑ CPA El Substance l r Abuse Care
El Day Treatment ❑ RTC El Cty regular Foster Care
El Kinship Care El Group Home El Ind.Living
❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
El Therapeutic(Behavior Modification) El Secure El Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
El Sex Offender El AggressiveNiolent ❑ Substance Abuse El Truancy
ID Self-destructiveElDelin Delinquency ID Victim Behavior ❑ Depression
q y ❑ Special Medical Needs ❑ Behavior Modification El Anger Management
El Other (Explain)
Appropriate Educational Services:
❑ Special Ed. El Public School El Day Treatment
El On-grounds School El Additional Tutoring
El Independent Living Training El Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) El Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: /!
Weld County Clerk to the Boa d
`•.�, ► BOARD OF SOCIAL SERVICES,
,� �J�i� •EHALF OF THE
TMENT OF SOCIAL SER CES
1861 : w :�•. l �
By:
t eputy Clerk t avid E.Long,Chair Jul 0 2 2003
APPROVED AS TO FO ` ��,
--� CONTRACTOR
County ey
Shiloh House
6400 W Coal Mine Ave
Littlet ,-€&8 123
By: ) c•-e.
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
irector
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE I �
RESIDENTIAL TREATMENT CENTER SERVICES
�d fa.
THIS AGREEMENT made this day ofc�CC/ 2003 between the Board of Weld Sjs
County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Shiloh House, 6400 W Coal
Mine Ave, Littleton, CO 80123,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$34.13 per day for children placed within
the Residential Treatment Center identified as Provider ID#70967. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
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Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 70967
Shiloh House Yarrow
7227 S Yarrow Ct
Littleton CO 80123
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: 1W 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement,had one or more
public transactions (federal, state, and local)terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the l5th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator)within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
•
Contract No: TY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services 0 Placement with Relative 0 Cty CC Foster Care ❑ Shelter Care 0 Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA 0 RTC ❑ Cty regular Foster Care
❑ Day Treatment 0 Kinship Care 0 Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) 0 Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy 0 Victim Behavior ❑ Depression
❑ Self-destructive 0 Delinquency 0 Special Medical Needs ❑ Behavior Modification ❑ Anger Management
O Other (Explain)
Appropriate Educational Services:
O Special Ed. ❑ Public School 0 Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ it has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first ab_ovee written.
ATTEST:ATTEST: "' f ��`%/�
Weld County Clerk to the Board
i.,*) Z► BOARD OF SOCIAL SERVICES,
< /J s, •EHALF OF THE
RTMENT OF SOCIAL SERVICES
r 1861 �' '" '•
By: 124 ♦.rid,. :;Qir , By:
Deputy Clerk t. � �oA avid E. Long,C air L 0 2 2003
APPROVED AS TO FO! I _St
CONTRACTOR
County Atto ey
Shiloh House
6400 W Coal Mine Ave
Little n, C 123
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
uector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made thisr'day of 2003 between the Board of Weld
County Commissioners, sitting as the Board of Social Se ices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Shiloh Home, 6400 W Coal
Mine Ave, Littleton, CO 80123, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$36.92 per day for children placed within
the Residential Treatment Center identified as Provider ID#1500860. These services
will be for children who have been deemed eligible for social services under the statutes,
rules and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 1500860
Shiloh Home, Inc.
1324 E Victory Way
Craig, CO 81625
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
- Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
•
•
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
El It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
• Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ten.
ATTEST: datele l/ve
Weld County Clerk to the Board
,`•!aECIL ► BOARD OF SOCIAL SERVICES,
��i�••EHALF OF THE
•+C�%`� � "� 'TMENT OF SOCIAL SERVICES
1861
B ': �GG �..S i �i� By:
Deputy Clerk t �p David E. Long, JUL 0 2 7nn�
APPROVED AS TO FO',���'
—�--� CONTRACTOR
ty-Alto ey
Shiloh Home
6400 W•Coal Mine Ave
Littleto ', Cp-SS4
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D ector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE `33b
RESIDENTIAL TREATMENT CENTER SERVICES
THIS AGREEMENT made this; —day of k l et2003 between the Board of Weld //
County Commissioners, sitting as the Board of Social Sices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and The Mountain Star Center, 3520
W Oxford Ave, Denver, CO 80236, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$43.63 per day for children placed within
the Residential Treatment Center identified as Provider ID#13363. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services ADD 3 �7c�C9
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include,but are not limited to:
Child Maintenance (food, shelter, clothing,personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 13363
The Mountain Star Center(At Ft. Logan)
4177 S Knox Ct - Fl
Denver CO 80236
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV, Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which maybe
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15`h and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator)within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
to
Agreement to Purchase
RTC Services
•
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
��it�te�n.�
ATTEST: ��7 /rT�(/(/G� j
Weld County Clerk to the Board
BOARD OF SOCIAL SERVICES,
�J rBEHALF OF THE
W a� RTMENT OF SOCIAL SERVICES
B • 4.��c�,� ' By:
Deputy Clerk t �C^�.�/ , David . Long, hair JUL 0 2 741n1
APPROVED AS TO FO''
I`
CONTRACTOR
County Attorney
The Mountain Star Center
3520 W Oxford Ave
Denver, CO 80236
By: ail naZe
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: 14A,OLL�l✓
director
12
Agreement to Purchase
RTC Services
Contract No: 1W 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
nd
THIS AGREEMENT made this cr day ofo 2003 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 called "County" and Third Way Center, PO Box
61385, Denver, CO 80206, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$40.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#49487. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services 5?DC j_/7ad
•
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation(including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 49487
Third Way Center- York
1295 York St
Denver CO 80206
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION IL MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
s
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator)within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department(Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract'No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family O Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST:
Weld County Clerk to the Board
fica`Z► BOARD OF SOCIAL SERVICES,
EHALF OF THE
r
TMENT OF SOCIAL SERVICES
1861• (' �� ��
By: t e_ !1:�. !S`.�!. By:
teputy Clerk t �1 = `� David E. Long,C JUL 0 2 2003
APPROVED AS TO FO
CONTRACTOR
County Atto e
Third Way Center
PO Box 6 :5
Denver O 80206
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
hector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
/O3
nd •
THIS AGREEMENT made this c day of, G , 2003 between the Board of Weld 9.. •
County Commissioners, sitting as the Board of Social Services, on behalf of the Weld County 9.9
Department of Social Services, hereinafter called "County" and Third Way Center, PO Box
61385, Denver, CO 80206, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$40.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#65346. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services c,7QD,5 /7ad
•
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include, but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 65346
Third Way Center-Pontiac
1735 Pontiac St
Denver CO 80220
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible,permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
6
Agreement to Purchase
RTC Services
. Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15th and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
a
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
El Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? El Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services O Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living El Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual ❑ Family ❑ Group
Appropriate Treatment:
El Sex Offender El AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
El Self-destructive El Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School ❑ Day Treatment
❑ On-grounds School ❑ Additional Tutoring El Independent Living Training ❑ Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
❑ It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: LA/1444
Weld Clerk to the Board
BOARD OF SOCIAL SERVICES,
QJ�`' •EHALF OF THE
e.
TMENT OF SOCIAL SERVICES
1861
By: q By:
Deputy Clerk t` i V �� David E. ong, Chair UL 0 2 2003
APPROVED AS TO FO' tu' -.►�
CONTRACTOR
County Atto ey
Third Way Center
PO Box 61385
Denver, 06
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Di ector
12
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
AGREEMENT TO PURCHASE
RESIDENTIAL TREATMENT CENTER SERVICES
Ad p
THIS AGREEMENT made this( day of`J2003 between the Board of Weld
County Commissioners, sitting as the Board of Social Se ices, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Third Way Center, PO Box
61385, Denver, CO 80206, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Residential Treatment Center.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. County agrees to purchase and Contractor agrees to provide Room and Board services
which are listed in this Agreement at a rate of$40.00 per day for children placed within
the Residential Treatment Center identified as Provider ID#77810. These services will
be for children who have been deemed eligible for social services under the statutes, rules
and regulations of the State of Colorado.
2. Contractor shall be reimbursed by Medicaid for services provided to County children
placed with Contractor. Medicaid reimbursement shall be based off of the State Vendor
Rate for the approved Level of Care. The assessment instrument used to determine the
Level of Care will be the Colorado Client Assessment Record (CCAR) as per outlined in
the Department of Health Care policy and Finance, Staff Manual Vol. 8, Section
8.765.30.
3. This Agreement shall be in force from July 1, 2003, until the end of the Colorado fiscal
year, June 30, 2004; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
1
Agreement to Purchase
RTC Services
O7OO3 --i>ad
Contract No: PY 03/04-SS-23A-RTC
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement as Room and Board costs for Residential
Treatment Center facility services, as outlined in the Department of Health Care policy
and Finance, Staff Manual Vol. 8, Section 8.765.503 may include, but are not limited to:
Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff.
2. The services reimbursable by Medicaid for treatment services under this Agreement, as
outlined in the Department of Health Care policy and Finance, Staff Manual Vol. 8,
Section 8.765.502 may include,but are not limited to: Direct Therapy Staff, Other
Treatment Staff(i.e. evaluation services, treatment supervision, treatment liaison, medical
services, and direct child care staff), Administration, Administrative Overhead,
Transportation (including client travel), Therapeutic Leave Days (may be reimbursed for
up to 52 therapeutic leave days per calendar year), Therapeutic Recreation and Staff, and
Community Liaison Staff.
3. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
4. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
5. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
6. Any transportation costs to be incurred on behalf of this child that are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
2
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. Contractor will provide the purchased care and services at:
Facility ID#: 77810
Third Way Center- Lincoln
1133 Lincoln
Denver CO 80203
8. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
9. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1)
Ordinary medical care, and 2) Emergency medical, surgical or dental care for said child
after making reasonable efforts to contact the County to obtain consent. Emergency care
is defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in person-to-person communication, not through phone mail
messages.
3. During regular work hours, the Contractor will make every effort to notify the assigned
caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental
issues prior to granting authorization. During non-regular work hours, weekends and
holidays, the Contractor will contact the Emergency Duty Worker at the pager number
(970) 350-8389.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
3
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period.
Such written permission may be in the treatment/case plan. Further, Contractor and
County will also secure, where possible, permission from parents or guardians of the
child placed with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the legal status of the child, anticipated living
arrangement and the anticipated educational arrangement for the child upon completion.
Also included will be the anticipated date for discharge from treatment purchased as well
as provisions concerning the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
4
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State
law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Abide by the policy and procedures as outline with the State of Colorado rules in Staff
Manual Volume VII, 7.714.90, regarding the use of restraints in an emergency situation.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
9. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
10. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
5
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
12. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
13. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at RTC level.
14. Schedule physical examinations within 14 days of placement and forward all appropriate
information to the County.
15. Schedule Dental examinations within 60 days of placement and forward all appropriate
information to the County.
16. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students will be conducted every 3 years and reviewed every year. If
the IEP is due while the child is in placement, the Contractor will complete or obtain a
completed IEP. A copy will then be forwarded to the County.
17. Assure and certify 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 or 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 (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
6
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or effect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
7
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned client through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. All reimbursement requests shall be submitted to and approved by the approved by the
appropriate County staff. Reimbursement for placement services shall be paid from the
date of admission up to, but not including, the day of discharge. Furthermore, Medicaid
payments for RTC treatment services are not permitted on the day of discharge and shall
not be limited to funds encumbered in this contract and shall also include Medicaid funds
for RCT treatment programs paid by the Department of Health Care Policy and
Financing. Payment for placement services will not be provided for clients on escape
status unless it has been previously approved by the County. Reimbursement requests for
treatment costs for clients enrolled in RTC programs shall be submitted to the Medicaid
Fiscal Agent in accordance with instructions provided by such Fiscal Agent. The
Contractor shall forward copies of such billings to the County on a monthly basis.
7. In the event that a Contractor receives payment for a discharge day, regardless of funding
source, the Contractor shall refund those dollars forthwith.
8. The purpose of these requirements is to provide minimum assurance the Contractor has
adequate accounting and budgeting information available to allow management to
maintain a financially viable enterprise.
A. The Contractor must have in place a double entry accounting system, which
complies with generally accepted accounting principles (GAAP). All expenses
must be posted to the double entry accounting system. Billings for services must
be reconcilable to the double entry accounting system. The vendor must have
adequate time keeping and cost allocation systems to allocate salary cost and
indirect cost to appropriate cost centers.
B. All billing by the Contractor must be in a format approved by the Fiscal Agent or
County. The Contractor must provide all supporting documentation requested by
the Division of Youth Corrections. Contractors must bill Fiscal Agent and
County at least once a month. Contractor may bill twice a month on the 15`h and
the last day of the month, for services rendered. Bills will be returned unpaid if
the bills do not conform to the approved format of the documentation is
inadequate.
C. The Contractor must have an annual audit of their financial statements by an
independent public accounting firm if the Contractor receives state funds. If the
Contractor is a government agency that has an independent audit done by another
agency of that government, their audit meets this requirement. The audits of
RCCFs and RTCs must be completed and a copy provided to the State
8
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
Department of Human Services (Attn: RTC Administrator) within 90 days after
the end of the Contractor's fiscal year. The audited financial statements must
contain supplemental statements providing detailed financial information for the
expenditures of this contract. Contractors that are subsidiary of a parent
organization must submit separate financial statements for the subsidiary that
detail each of the Contractor's facilities and/or programs that provide services for
the Department and also must reconcile with the consolidated statements of the
parent organization. In cases where audit deficiencies are noted, a plan of
corrective action shall be submitted to the Department (Field Audits) for approval
within four(4) months of the date of the audit.
D. If Contractors do not submit their annual audit or refuse to disclose financial
information regarding the operation of the program in a timely manner, the Fiscal
Agent may withhold payment until the audit and/or requested information is
submitted.
E. If the Contractor is a sub recipient of federal funds, the Contractor is responsible
for complying with all appropriate federal requirements for an adequate
accounting system, audits, reporting and financial management. In cases where
audit deficiencies are noted, a plan of corrective action shall be submitted to the
Department (Field Audits) for approval within four(4) months of the date of the
audit.
F. Failure to comply with any of these requirements is justification for the County to
cancel the contract.
9. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
10. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
9
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
11. No portion of this Agreement shall be deemed to constitute a waiver of any immunities
the parties or their officers or employees may possess, nor shall any portion of this
Agreement be deemed to have created a duty of care that did not previously exist with
respect to any person not a party to this Agreement. The parties hereto acknowledge and
agree that no part of this Agreement is intended to circumvent or replace such
immunities.
12. The Director of Social Services or designee may exercise the following remedial actions
should s/he find the Contractor substantially failed to satisfy the scope of work found in
this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean
incorrect or improper activities or inaction by the Contractor. These remedial actions are
as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor 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. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
13. The contractor shall promptly notify Social Services in the event that the Contractor
learns of any actual litigation in which it is a party defendant in a case, which involves
services provided under the agreement. The Contractor, 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, reorganizations and/or
foreclosure.
10
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR RTC SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care
O CORE Services O Receiving Home O CPA O Substance l r Abuse Care
❑ Day Treatment ❑ RTC ❑ Cty regular Foster Care
O Kinship Care O Group Home ❑ Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) ❑ Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family ❑ Group
Appropriate Treatment:
❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse O❑ Truancy El Victim Behavior ❑ Depression
Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification Anger Management
❑ Other (Explain) ❑
Appropriate Educational Services:
❑ Special Ed. ❑ Public School O Day Treatment
❑ On-grounds School ❑ Additional Tutoring O Living Independent p Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2004,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) ❑ Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
11
Agreement to Purchase
RTC Services
Contract No: PY 03/04-SS-23A-RTC
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: i� eu44
Weld County Clerk to the Board
�'•p" Era t BOARD OF SOCIAL SERVICES,
/!j i�l. •EHALF OF THE
».,
W. � a\�lei� �a�•RTMENT OF SOCIAL SERVICES
1861 � ac
By:
Deputy Clerk t+�i N14 David E.Long, JUL 0 2 2003
APPROVED AS TO FO'
CONTRACTOR
County Atto y
Third Way Center
PO Box 61385
Denver, C 206
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Di c or
12
Agreement to Purchase
RTC Services
a .
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY,CO 80632
VI
I WEBSITE:wvrw.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 23, 2003
Board of County Commissioners /
FR: Judy A. Griego, Director, Social Service s0 3,u1c1
Au
RE: Agreements to Purchase Residential Treatment Center(RTC) Services
Between Weld County Department of Social Services with Various
Vendors
Enclosed for Board approval are Agreements to Purchase Residential Treatment Center(RTC)
Services between the Weld County Department of Social Services with various vendors. These
yearly Agreements are in accordance with Board approved policies of Sections 2.320 and
2.902.22 of the Weld County Department of Social Services Operations Manual. These
Agreements were reviewed at the Board's Work Session of June 23, 2003.
The major provisions of the Agreements are as follows:
1. The term period is from July 1, 2003 through June 30, 2004. •
2. The Department agrees to reimburse vendors at rates including room and board costs and
excluding Medicaid treatment costs. The rates are as follows:
Rates:
A. Courthouse, Inc.—Marilee Center $27.22 per day
B. Courthouse,Inc.—Daybreak-Princeton $27.22 per day
C. Devereux Cleo Wallace—Colorado Springs $41.74 per day
D. Devereux Cleo Wallace-Westminster $41.74 per day
E. El Pueblo Boys and Girls Ranch $31.52 per day
F. Monarch Youth—Blue Mountain Ranch $41.00 per day
G. Monarch Youth -Wilderness Treatment Center $41.00 per day
H. Monarch Youth—Prairie View Treatment Center $41.00 per day
I. Monarch Youth—Byron Grizmore Treatment Center $41.00 per day
J. Monarch Youth—Fox Drive Treatment Center $41.00 per day
K. Shiloh Homes—Shiloh House Estes $34.13 per day
L. Shiloh Homes—Denver $34.13 per day
M. Shiloh Homes—Shiloh House Portland $34.13 per day
N. Shiloh Homes—Shiloh House Sheridan $34.13 per day
0. Shiloh Homes—Shiloh House Yarrow $34.13 per day
P. Shiloh Homes—Craig $36.92 per day
Q. The Mountain Star Center $43.63 per day
R. Third Way Center—York $40.00 per day
2003-1720
MEMORANDUM Page 2
David E. Long, Chair,Board of County Commissioners
June 23, 2003
S. Third Way Center—Pontiac $40.00 per day
T. Third Way Center—Lincoln $40.00 per day
If you have any questions,please telephone me at extension 6510.
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