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Home My WebLink About20211437.tiffCunkvaCk-'IDiftgl3 Consenk WT,nc0.0, 5a/23 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: May 2, 2023 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, I-Iuman Services RE: Agreement Amendment #5 with Amanda Hartshorn dba Creative Nursing LLC Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement Amendment #5 with Amanda Hartshorn dba Creative Nursing LLC. The Department has an Agreement with Amanda Hartshorn fora Nurturing Program and Foster Care/Adoption Support Services. This Agreement is known to the Board as Tyler ID# 2021-1437. The agreement is now being amended to renew fora third and final year, for the period June 1, 2023 through May 31, 2024, and to make changes to the Scope of Services and Rate Schedule as noted below. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Scope of Services Changes. • Add Foster Parent Training and update the terms as requested by the Department. Rate Schedule Changes: • Updates to the terms as requested by the Department. • Updates to the rates as requested by the Contractor. Rate changes are noted below. Nurturing Program $110.00 Hour Consultation (Includes 20 miles from 33681 County Road 13, Windsor, CO 80550) $110.00 Hour Case Management/Education (Includes 20 miles from 33681 County Road 13, Windsor, CO 80550) $135.00 Hour Nursing Assessments & Observations (Includes 20 miles from 33681 County Road 13, Windsor, CO 80550) $100.00 Hour Nurturing Program: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $80.00 Each Nurturing Program: No Show (Max of 2 no shows or 2 hours/month/client) $0.55 Mile Nurturing Program: Mileage* Foster Care/Adoption Support $135.00 Hour Foster Parent Training: In Home or Community (3 Hour Training)- $135.00 Hour Foster Parent Training: In Office/Video (3 Hour Training) $135.00 Each Foster Parent Training: No Show (Max oft no shows or 2 hours/month/client) Pass -Around Memorandum; May 2, 2023 - CMS ID 6913 SDI'5/t/23 Page 1 2oZ . -1(131 01200ct3 PRIVILEGED AND CONFIDENTIAL I do not recommend a Work Session. I recommend approval of this Agreement Amendment #5 and authorize the Chair to sign. Perry L. Buds, Pro -tern Mike Freeman Scott K. Janes Kevin Ross Lori Saine Schedule Work Session Other/Comments • Pass -Around Memorandum; May 2, 2023 - CMS ID 6913 Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND AMANDA HARTSHORN DBA CREATIVE NURSING LLC This Agreement Amendment, made and entered into 0 day of 1' 1 , 2023, by and between the Board of Weld County Commissioners, on behalf of the Weld County Dep ent of Human Services, hereinafter referred to as the "Department", and Amanda Hartshorn DBA Creative Nursing LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into m Agreement for Nurturing Program and Foster Care/Adoption Support (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1437, approved on May 26, 2021. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement was set to end on May 31, 2022. The Original Agreement was amended on: • March 7, 2022 to reflect contractor's name change from Amanda Hartshorn to Amanda Hartshorn DBA Creative Nursing LLC. • April 27, 2022 to extend the term date through May 31, 2023. • May 16, 2022 to update section 17 of the Agreement, Contractors Address. • September 7, 2022 to amend Exhibit C, Scope of Work. • The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2021-1437. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement as of June 1, 2023: 1. Exhibit C, Scope of Services, is hereby amended as attached. 2. Exhibit D, Rate Schedule, is hereby amended as attached. 3. Term: This agreement is being renewed for a third, and final year, for the period of June 1, 2023 through May 31, 2024. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTES BY: BOARD OF COUNTY COMMISSIONERS rk to the Boa d WELTY, COLORADO Deputy Cle Mike Freeman, Chair MAY 0 8 2023 CONTRACTOR: Amanda Hartshorn DBA Creative Nursing LLC 33681 County Road 13 Windsor, Colorado 80550 By: N MSN (Apr 21, 2023 12:04 MD, Amanda Hartshorn, RN, MSN Date: Apr 21, 2023 �i- //7137 EXHIBIT C SCOPE OF SERVICES Contractor will provide Nurturing Program, and Foster Care/Adoption Support, as referred by the Department. All services will be provided by Creative Nursing LLC. Program Area: Nurturing Program 1. Nursing Consultation: a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Evidence Based Research, and professional experience. ii. Education regarding medical diagnosis and treatment. iii. Utilization of credible resources such as Children's Hospital Online and Mayo Clinic as needed to enhance education. iv. Setup and facilitation of home visit or medical appointments and record reviews. v. Meeting with Department staff and caseworkers regarding specific cases to determine needs and goals. vi. Ongoing documentation and/or communication of objective observations and interactions with the client to the caseworker via phone or email. vii. Contractor will serve as a liaison between the client, caregiver and the Department for the purpose of setting up and/or attending medical appointments. viii. Health Service Plan. Contractor will work with Department, other professionals, client, and caregiver to create an initial Health Service Plan, and will obtain current provider and service information pertinent to medical and mental needs. b. Anticipated Frequency of Services: i. Established ongoing office hours at the Department as needed. c. Anticipated Duration of Services: i. Services shall be for the term of the Agreement. d. Goals of Services: i. Collaboration with Department staff to meet established goals. ii. Education of Department staff to gain a better understanding of medical information and needs of identified clients. iii. Education of Department staff and caregivers to better assist caregivers in navigating the healthcare system and understanding medical information. iv. Case management support to the Department and client. e. Outcomes of Services: i. Assessment of case -specific medical issues that may be creating child protection issues. ii. Establishment of short-term and long-term goals for each identified case. iii. Increased understanding of medical information and healthcare system by Department staff, allowing Department staff to better assist caregivers in mitigating or eliminating child protection issues. f Target Population: i. All Department staff ii. All clients as referred by Department. g. Language: 1 i. English. E. Medicaid Eligibility: i. This service is not Medicaid eligible. Service Access and Transportation: i. Contractor does not provide transportation. ii. Services will be primarily accessed onsite at the Department but may also be accessed outside of the Department at a mutually agreed upon location. Contractor may also be accessed via phone, email, and virtual platform. 2. Nurtarirg Program: E. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Information gathering. Information will be collected from the Department, other professionals, the client, and the caregivers to the determine medical and mental health care needs of the client. Contractor will work collaboratively with all parties to gather and review all necessary information. ii. Goal setting. Short-term and long-term goals will be established pertinent to medical and mental health needs. iii. Health Service Plan. Contractor will work with Department, other professionals, client, and caregiver to create an initial Health Service Plan, and will obtain current provider and service information pertinent to medical and mental needs. iv. Hands-on Demonstration. Contractor will provide skilled hands-on demonstration to caregivers regarding performance of ordered medical tasks in a safe and competent manner. Demonstration will include skilled nursing education around ordered interventions. Contractor will not provide ongoing nursing support such as Home Health Care Services. v. Contractor will provide hands on nursing skilled education by directing and educating caregivers on ordered interventions. Contractor will not provide ongoing nursing support such as Home Health Care Services. h. Anticipated Frequency of Services: i. Two (2) to ten (10) hours per week, based on needs of client. a. Anticipated Duration of Services: i. One (1) to ninety (90) days with option to extend upon request by either party and with approval of the Department. d. Goals of Services: i. Education of client and/or caregiver regarding client specific medical information to promote increased understanding and knowledge of information and needs. ii. Hands-on skilled nursing demonstration of ordered medical interventions to promote understanding and competency by client and/or caregiver. iii. Hands-on education of client and/or caregiver regarding navigation of the healthcare system to promote confidence and increase ability to navigate the system successfully. e. Outcomes of Services: i. Client and/or caregiver will demonstrate: 1. Increased knowledge and understanding of the client's medical information and needs, including self -care, ongoing medical needs and requirements for a safe environment. 2. Increased understanding and competency regarding ordered medical interventions through hands-on performance of interventions. Client will demonstrate safe, accurate and confident performance of interventions. 2 3. Increased confidence and ability to navigate the healthcare system independently and successfully, and confidence accessing additional resources as needed. 4. Decreased child protection issues mitigated through increased knowledge, understanding of client's medical issues, needs and ordered interventions. f. Target Population: All ages and genders. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor does not provide transportation. ii. Services will be provided in person in the client's home, unless otherwise approved by the Department. Program Area: Foster Care/Adoption Support 1. Foster Parent Training: a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Registered Nurse (RN) will present education to foster parents in an individual or group setting. 1. Content covered will include: a. Over the counter (OTC) medications b. Medication Concepts c. Uses and forms of drugs d. Medication orders e. Medication administration records (MAR) f. Medication Minder boxes g. Medication administration Procedure h. Medication errors i. Medication storage j. Seven (7) Rights of Medication Administration k. The six (6) components of a physician order 1. Common abbreviations and measurement equivalents ii. RN will use developed syllabus and qualifications in alignment with the State of Colorado Regulatory Agencies. iii. Validation of competency will be obtained via a written exam. iv. A Certificate of Completion can be provided upon request. b. Anticipated Frequency of Services: i. Three (3) one (1) hour sessions. ii. Any combination of three (3) hours total training. c. Anticipated Duration of Services: i. Three (3) hour trainings may be increased or decreased, depending on group size. ii. Not to exceed a total of six (6) hours. d. Goals of Services: i. Assist foster parents in gaining skills for proper medication administration. 3 2. Outcomes of Services: i. Safe medication administration of ordered medications. ii. Understanding medication order, how to obtain them and administer correctly and safely. iii. OTC medications and using them correctly and safely. Target Population: i. Foster Parents. g. Language: i. English. z. Medicaid Eligibility: i. This service is not Medicaid eligible. . Service Access and Transportation: i. In office/In home. ii. This service can be offered upon request, with two (2) week prior notice. Terms 1. Contactor understands and will comply with all aspects of the referral authorization, billing and tracking requ renients as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. 2. Contactor agrees to receive referrals for services through e-mail and will provide an identified e-mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknm ledges that services provided prior to the authorized start date or outside the scope of services on the r:fe-ral form will not be eligible for reimbursement. 3. Contactor will respond to the Mental Health and Support Services Team CWServiceReferral(&,weldeov.com within three (3) business days regarding the ability to accept the received referral. 4. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred serves_ If the client does not respond after three (3) attempts in the first seven (7) days of the referral pericd, :he Contractor will notify the caseworker and the Mental Health and Support Services Team (HS- CWSeeviceReferral(aiiweldeov.com). 5. Contadar acknowledges that any and all modifications to an existing referral must be approved through the Mental Health and Support Services Team(HS-CWServiceReferral(a,weldeov.com). No other Department staff or other party to the case may authorize services or modifications to services. 6. Contactor understands that "no shows" are defined as unexcused and unplanned/uncommunicated abseices for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Conttador understands that the Department will not reimburse for "no-shows". Contractor understands that lre.Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the partof case participants who cancel without 24 -hour notice. After three (3) "no-shows", Contractor will place cient on a behavioral plan requiring attendance or discharge the client from services. Contractor 4 must inform the caseworker and the Mental Health and Support Services Team (HS- CWServiceReferralweldgov.com) within three (3) days of when the client is placed on a behavioral plan or discharged 7. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Mental Health and Support Services Team(HS-CWServiceReferral(&,weldgov.com) immediately via email, to discuss service continuation. 8. Contractor will identify, in detail, areas of continued concern and make recommendations to the caseworker in a monthly report regarding continuation of services and/or the need for additional services. 9. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported to the caseworker and the Mental Health and Support Services Team(HS-CWServiceReferral(&,weldgov.com) immediately AND on the required monthly report. 11. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Mental Health and Support Services Team. Any changes to visitation referrals will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 12. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Mental Health and Support Services Team, and the facilitator documents in the meeting notes the timeframe that the provider attended and when participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the meeting notes. Stuffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone or virtually, if approved by the Department. 13. On a monthly basis, the Contractor will notify the Mental Health and Support Services Team (HS- CWServiceReferral(a,weldgov.com) of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information 5 The Department reserves the right to decline the new staff members managing and/or administering cervices to Department clients. 14. Comiliance with Child and Family Services Review The Chid and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contactor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this.vgaeement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR) and will address the aforementioned three areas when come leing monthly reports as required by Paragraph 9 of this Exhibit. 15. Certlication Contactor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licences, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this ,Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor priorto the start of any Agreement. 16. Trairing Contactor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of regis ration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 17. Subpoenas Contactor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Welc County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For tiispurpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contactor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 18. Mon -toting and Evaluation Contactor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department, and the Contractor. Contactor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery., service quality, documentation, and invoicing during referral period and after services have cons udbd. The Contractor will require clients to sign releases of information. Contractor understands that the Cepartment will not reimburse for services rendered to Department clients until releases of information are ojtaiined. Contactor shall permit the Department, and any other duly authorized agent or governmental agency, to monior all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, 6 special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 7 EXHIBIT D RATE SCHEDULE 1. Funcing and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under his Agreement at the rate(s) specified below in Paragraph 2, Fees for Services. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. For services funded through Core Services, Contractor agrees to accept reimbursement through ACH direct depcsitone time per month. If Contractor is not currently set up with the State of Colorado to accept direct deposit Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check, deposit slip or bank letter. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. For services not funded through Core Services; Contractor agrees to accept payment through County Warrant when funding source does not allow for direct deposit. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Program 1.rea N■rtving Program Rate $110.00 1 nit Type Hour Ser,ice Name Consultation (Includes 20 miles. from 33681 County Road 13, Windsor, CO 80550) $110.00 Hour Case Management/Education (Includes 20 miles from 33681 County Road 13, Windsor, CO 80550) $135.00 Hour Nursing Assessments & Observations (Includes 20 miles from 33681 County Road 13, Windsor, CO 80550) $100.00 Hour Nurturing Program: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $80.00 Each Nurturing Program: No Show (Max of 2 no shows or 2 hours/month/client) $0.55 Mile Nurturing Program: Mileage* Foster Care/Adoption Support $135.00 Hour Foster Parent Training: In Home or Community (3 Hour Training) $135.00 Hour Foster Parent Training: In Office/Video (3 Hour Training) $135.00 Each Foster Parent Training: No Show (Max of 2 no shows or 2 hours/month/client) *Mileage for distances exceeding 20 roundtrip miles from 33681 County Road 13, Windsor, CO 80550 3. RegLost for Reimbursement and Supporting Documentation Contactor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 1h day of the month following the month of service, but no later than 45 days from the date of service for each client receiving ongoing services. Contractor shall prepare and submit monthly a Request for Reimbursement and monthly report including other supporting documentation, if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 of this Agreement. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Time(s) of service (i.e. 2-4pm) b. Location of where the service took place (i.e. clinician's office, client's home, in the community.) c. Clinician/therapist name d. What interventions were used, recommendations and/or goals discussed, progressions towards goals, and client engagement. e. For mileage reimbursement, if applicable, the mileage accumulated minus roundtrip mileage that is included in the rate, starting location, and ending location. F. Any and all safety concerns. When submitting a Request for Reimbursement for a one-time service, the contractor shall submit the first and last page of the evaluation/report to confirm proof of services rendered. The full evaluation/report should be submitted by the contractor to the caseworker. For Monitored Sobriety services, proof of services rendered shall be the test result. Requests for Reimbursement and/or supporting documentation received after the 7`h day of the month may delay payment. Requests for Reimbursement and/or supporting documentation received after 45 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 45 -day deadline may result in termination of the Agreement. 4. Payment The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: The service being provided by the contractor is not a Medicaid eligible service; a. The service is not deemed medically necessary; b. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; c. A Medicaid provider is not available to provide the needed service; d. Medicaid is exhausted for the needed service; or e. Medicaid denied service. f. The client is not eligible for Medicaid. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Remedies The Director of Human 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 sa_isfy the scope of work shall be defined to mem incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: 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 Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. Incorreet payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 6. Financial Management At al times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMB Circular A-133. SIGNATURE REQUESTED: Weld/Hartshorn, Amanda dba Creative Nursing LLC Amendment #5 - 2023-24 Final Audit Report 2023-04-21 Created: 2023-04-21 By: Lesley Cobb (cobbxxlk@co.weld.co.us) Status: Signed Transaction ID: CBJCHBCAABAAUQhKU7-7JdKxScJhexQkeIiheEOJ6xgs "SIGNATURE REQUESTED: Weld/Hartshorn, Amanda dba Cre ative Nursing LLC Amendment #5 - 2023-24" History ,t Document created by Lesley Cobb (cobbxxlk@co.weld.co.us) 2023-04-21 - 5:49:09 PM GMT- IP address: 204.133.39.9 2. Document emailed to nurseconsult7@gmail.com for signature 2023-04-21 - 5:49:55 PM GMT tt Email viewed by nurseconsult7@gmail.com 2023-04-21 - 5:53:22 PM GMT- IP address: 74.125.214.70 4 Signer nurseconsult7@gmail.com entered name at signing as Amanda Hartshorn, RN MSN 2023-04-21 - 6:04:08 PM GMT- IP address: 174.231.80.139 4 Document e -signed by Amanda Hartshorn, RN MSN (nurseconsult7@gmail.com) Signature Date: 2023-04-21 - 6:04:10 PM GMT - Time Source: server- IP address: 174.231.80.139 :i Agreement completed. 2023-04-21 - 6:04:10 PM GMT Names and email addresses are entered into the Acrobat Sign service by Acrobat Sign users and are unverified unless otherwise noted. Powered by Adobe Acrobat Sign Contract Form New Contract Request Entity Information Entity Name* HARTSHORN, AMANDA Entity ID* O043381 Contract Name. HARTSHORN. AMANDA DBA CREATIVE NURSING LLC (AGREEMENT AMENDMENT #5 PY 202 3-241 Contract Status CTB REVIEW Contract ID 6913 Contract Lead. COBBXXLK ❑ New Entity? Parent Contract ID 20211437 Requires Board Approval YES Contract Lead Email Department Project cobbxxlk@co.weld.co.vs Contract Description * BID# B2100042. MINOR SCOPE, RATE AND TERM CHANGES. TERM 6 1 23-5;'31,'24. Contract Description 2 CONSENT PA ROUTING THROUGH NORMAL APPROVAL PROCESS. ETA TO CTB 05 : 04 2023. Contract Type. AMENDMENT Amount. 90.00 Renewable. NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices:1 veidgov.co rtZ Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COU NTYATTO RN EY YWELDG OV.COM Requested BOCC Agenda Date. 05 1032023 Due Date ©5;06/2023 Will a work session with BDCC be required?* NO Does Contract require Purchasing Dept to be included? if this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Co Effective Date Review Date 03,29,2024 Renewal Date Termination Notice Period Committed Delivery Date Expiration Date' 05131x2024 Contact Information Contact Info Contact Name Contact Type Purchasing Purchasi CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 04,`28 F2023 Final Approval C Appr ROCC Signed Date ACC Agenda Date 05.08; 2023 Originator COBB.LK Finance Approver CONSENT Contact Phone 1 Contact Phone 2 Purchasing Approved Date 04:28 2023 Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 04 28:2023 04;28,2023 Tyler Ref It AG 050823 0,orrlvac+l D4 -02 -if. PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: August 30, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment #4 with Amanda Hartshorn DBA Creative Nursing LLC Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement Amendment #4 with Amanda Hartshorn DBA Creative Nursing LLC. Ms. Hartshorn is a Registered Nurse who provides a Nurturing Program through the Department's Division of Child Welfare under the Agreement known as Tyler ID 2021-1437. Due to the Contractors change to an LLC in March 2022, we are amending Exhibit C, Scope of Work, to reflect that all services will be provided under Creative Nursing LLC. I do not recommend a Work Session. I recommend approval of the Agreement Amendment #4 and authorize the Chair to sign. Perry L. Buck Mike Freeman, Pro-Tem Scott K. James, Chair Steve Moreno Lori Saine Approve Recommendation Schedule Work Session Other/Comments: Pass -Around Memorandum; August 30, 2022 - MS 172A, Page e 1 Corfcnc Zon _ 11-B1 oaio7 /ZZ 012_009,4 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND AMANDA HARTSHORN DBA CREATIVE NURSING LLC. This Agreement Amendment, made and entered into `.h day of 5e: bey 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Amanda Hartshorn DBA Creative Nursing LLC., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Nurturing Program, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1437, approved on May 26, 2021. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement was set to end on May 31, 2022. • The Original Agreement was amended on: • March 7, 2022 to reflect contractor's name change from Amanda Hartshorn to Amanda Hartshorn DBA Creative Nursing LLC. • April 27, 2022 to extend the term date through May 31, 2023. • May 16, 2022 to update section 17 of the Agreement, Contractors Address. • The Amendment is identified by the Weld County Clerk to the Board of County Commissioners as document number 2021-1437. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Exhibit C, Scope of Services, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. oZoa/-i1/37 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST:ddrAtiti ‘Jd40;e/k• BY: erk to the Deputy Clerk COUNTY: BOARD OF COUNTY COMMISSIONERS WELD JOUNTY,COLORADO ames, Chair SEP 0 7 Z022 ONTRACTOR: Amanda Hartshorn DBA Creative Nursing LLC. 33681 County Road 13 Windsor, Colorado 80550 By: Amanda Hartshorn (Aug 25, 2022 09:30 MDT, Amanda Hartshorn, RN, MSN Aug 25, 2022 Date: foal '1`/61 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Home Based Intervention, as referred by the Department, and Case Consultation to Department staff, as needed. 2. All services will be provided by Creative Nursing LLC. 3. Contractor will provide case consultation services and case management to the Department. Services will include: i. Evidence Based Research, and professional experience. ii. Education regarding medical diagnosis and treatment. iii. Utilization of credible resources such as Children's Hospital Online and Mayo Clinic as needed to enhance education. iv. Setup and facilitation of home visit or medical appointments and record reviews. v. Meeting with Department staff and caseworkers regarding specific cases to determine needs and goals. vi. Ongoing documentation and/or communication of objective observations and interactions with the client to the caseworker via phone or email. vii. Contractor will serve as a liaison between the client, caregiver and the Department for the purpose of setting up and/or attending medical appointments. viii. Health Service Plan. Contractor will work with Department, other professionals, client, and caregiver to create an initial Health Service Plan, and will obtain current provider and service information pertinent to medical and mental needs. b. Anticipated Frequency of Services: i. Established ongoing office hours at the Department as needed. c. Anticipated Duration of Services: i. Services shall be for the term of the Agreement. d. Goals of Services: i. Collaboration with Department staff to meet established goals. ii. Education of Department staff to gain a better understanding of medical information and needs of identified clients. iii. Education of Department staff and caregivers to better assist caregivers in navigating the healthcare system and understanding medical information. iv. Case management support to the Department and client. e. Outcomes of Services: i. Assessment of case -specific medical issues that may be creating child protection issues. ii. Establishment of short-term and long-term goals for each identified case. iii. Increased understanding of medical information and healthcare system by Department staff, allowing Department staff to better assist caregivers in mitigating or eliminating child protection issues. f Target Population: i. All Department staff. ii. All clients as referred by Department. g. Language: i. English. 1 h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor does not provide transportation. ii. Services will be primarily accessed onsite at the Department but may also be accessed outside of the Department at a mutually agreed upon location. Contractor may also be accessed via phone, email, and virtual platform. 4. Contractor will provide Home -Based Services, as referred by the Department, to include Education, Nursing Assessments and/or Observation. Services will include: i. Information gathering. Information will be collected from the Department, other professionals, the client, and the caregivers to the determine medical and mental health care needs of the client. Contractor will work collaboratively with all parties to gather and review all necessary information. ii. Goal setting. Short-term and long-term goals will be established pertinent to medical and mental health needs. iii. Health Service Plan. Contractor will work with Department, other professionals, client, and caregiver to create an initial Health Service Plan, and will obtain current provider and service information pertinent to medical and mental needs. iv. Hands-on Demonstration. Contractor will provide skilled hands-on demonstration to caregivers regarding performance of ordered medical tasks in a safe and competent manner. Demonstration will include skilled nursing education around ordered interventions. Contractor will not provide ongoing nursing support such as Home Health Care Services. v. Contractor will provide hands on nursing skilled education by directing and educating caregivers on ordered interventions. Contractor will not provide ongoing nursing support such as Home Health Care Services. b. Anticipated Frequency of Services: i. Two (2) to ten (10) hours per week, based on needs of client. c. Anticipated Duration of Services: i. One (1) to ninety (90) days with option to extend upon request by either party and with approval of the Department. d. Goals of Services: i. Education of client and/or caregiver regarding client specific medical information to promote increased understanding and knowledge of information and needs. ii. Hands-on skilled nursing demonstration of ordered medical interventions to promote understanding and competency by client and/or caregiver. iii. Hands-on education of client and/or caregiver regarding navigation of the healthcare system to promote confidence and increase ability to navigate the system successfully. e. Outcomes of Services: i. Client and/or caregiver will demonstrate: 1. Increased knowledge and understanding of the client's medical information and needs, including self -care, ongoing medical needs and requirements for a safe environment. 2. Increased understanding and competency regarding ordered medical interventions through hands-on performance of interventions. Client will demonstrate safe, accurate and confident performance of interventions. 2 3. Increased confidence and ability to navigate the healthcare system independently and successfully, and confidence accessing additional resources as needed. 4. Decreased child protection issues mitigated through increased knowledge, understanding of client's medical issues, needs and ordered interventions. f. Target Population: All ages and genders. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor does not provide transportation. ii. Services will be provided in person in the client's home, unless otherwise approved by the Department. Terms 1. Contractor will respond to the Quality Assurance Team (HS-CWQualitvAssurance(a,weldeov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team HS- CWQualitvAssurance/d/weldgov.com. 3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 -hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWQualitvAssuranceweldgov.com. 4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(a,weldeov.com immediately via email, to discuss service continuation. 5. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 3 6. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 7. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by the caseworker, their supervisor, or the Family Support and Visitation Center. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Stuffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Quality Assurance Team, and the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the Client Verification Form. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 10. Contractor will notify the Quality Assurance Team HS-CWQualitvAssurance(&,weldeov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 4 SIGNATURE REQUESTED: Weld/Hartshorn Amend 4 with Exhibit C Final Audit Report 2022-08-25 Created: 2022-08-25 By: Windy Luna (wluna@co.weld.co.us) Status: Signed Transaction ID: CBJCHBCAABAAXWwRuruwuomfuJENbcMK7dt2bC5CXrPW "SIGNATURE REQUESTED: Weld/Hartshorn Amend 4 with Exh ibit C" History t Document created by Windy Luna (wluna@co.weld.co.us) 2022-08-25 - 3:28:14 PM GMT E'-► Document emailed to nurseconsult7@gmail.com for signature 2022-08-25 - 3:30:04 PM GMT t Email viewed by nurseconsult7@gmail.com 2022-08-25 - 3:30:22 PM GMT 05j Signer nurseconsult7@gmail.com entered name at signing as Amanda Hartshorn 2022-08-25 - 3:30:54 PM GMT ea Document e -signed by Amanda Hartshorn (nurseconsult7@gmail.com) Signature Date: 2022-08-25 - 3:30:55 PM GMT - Time Source: server Agreement completed. 2022-08-25 - 3:30:55 PM GMT Powered by Adobe Acrobat Sign Contract Form New Contract Request Entity Information Entity Name. CREATIVE NURSING LLC ❑ New Entity? Entity ID* 300045193 Contract Name. Contract ID CREATIVE NURSING LLD !AGREEMENT AMENDMENT 41 6275 Contract Status CTB REVIEW Contract Lead" WLUNA Contract Lead Email wluna2(uveldgov.com;cobbx xlkU,weldgov.com Parent Contract ID 20211437 Requires Board Approval YES Department Project If Contract Description (CONSENT) AMENDMENT TO UPDATE EXHIBIT C - SCOPE OF WORK. BID PB21 0004. TERM: 06:01 22 TO 05 r 31 r'23. Contract Description 2 PA IS BEING ROUTED THROUGH THE NORMAL PROCESS. ETA TO CTB 09 01i22. Contract Type. AMENDMENT Amount $0.00 Renewable. NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServicesAweldgov.co rn Department Head Email CM-HumanServices- DeptHead.weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY gWELDG OV.COM Requested BOCC Agenda Date. 09'07:2022 Due Date 09'03'2022 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter NSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 03'3112023 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Committed Delivery Date Expiration Date 0531;2023 Contact Type Contact Email Contact Phone I Contact Phone 2 Purchasing Approver Purchasing Approved Date CONSENT 08 29 2022 Approval Process Department Head JAMIE ULRICH DH Approved Date 08,'2912022 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 09?07/2022 Originator WLUNA Finance Approver CONSENT Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 08;29;2022 08'29,,2022 Tyler Ref # AG 090722 PRIVILEGED AND CONFIDENTIAL CC)YThI'Ct Cif I 5" 1 MEMORANDUM DATE: March 29, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2021-22 Core/Non-Core Contracted Services B2100042 Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement Amendments for 2021- 22 Core/Non-Core Contracted Services B2100042. The Department entered into Agreements with various Child Welfare service providers through the 2021-2022 Request for Proposal (RFP), Bid Number: B2100042, identified as Tyler ID 2021-0307. These Agreements were issued for a period of three (3) years with the option to renew annually. The Department is requesting to renew the current Agreements with no changes for sixteen (16) providers reflected in the attached list. Agreements will be renewed for the second year for the period of June 1, 2022 through May 31, 2023. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments and authorize the Chair to sign. Approve Recommendation Perry L. Buck Mike Freeman, Pro -Tern Scott K. James, Chair Steve Moreno Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Page 1 Cors-W-1-1 o5nu/2z. Cit2 f 64-0) 0,00c‘ 2021-1`-131 PRIVILEGED AND CONFIDENTIAL CMS Name Behavior Services of the Rockies Bid # B2100042 Bid Year 2021-22 Tyler ID 2021-1581 Centennial Mental Health B2100042 2021-22 2021-1579 Colorado State University B2100042 2021-22 2021-1583 Hartshorn, Mandee dba Creative Nursing LLC B2100042 2021-22 2021-1437 Jones, Dr. Jacob B2100042 2021-22 2021-1470 Northern Colorado Counseling (Rascon, Christina) B2100042 2021-22 2021-1467 Northern Horizon Behavioral Health - Nikki Tolle B2100042 2021-22 2021-1436 Reaching Hope B2100042 2021-22 2021-1547 Reece, Alison B2100042 2021-22 2021-1438 Rocky Mountain Kids B2100042 2021-22 2021-1465 Sovereignty Counseling - Annette Brown 82100042 2021-22 2021-1439 Specialty Counseling & Consulting B2100042 2021-22 2021-1466 The Hope Initiative 82100042 2021-22 2021-1582 Tindall and Associates B2100042 2021-22 2021-1606 VitalCare B2100042 2021-22 2021-1469 Withers Whisper -Andrea Hall B2100042 2021-22 2021-1471 Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Page 2 Karla Ford From: Sent: To: Subject: yes Lori Saine Weld County Commissioner, District 3 1150 0 Street PO Box 758 Greeley CO 80632 Phone: 970-400-4205 Fax: 970-336-7233 Email: isaine@weldgov.com Website: www.co.weld.co.us In God We Trust Lori Saine Tuesday, March 29, 2022 11:34 AM Karla Ford RE: Please Reply - PA FOR ROUTING: CW Core Non -Core 2021-22 Renewals B2100042 (CMS Various) Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Karla Ford <kford@weldgov.com> Sent: Tuesday, March 29, 2O22 1O:45 AM To: Lori Saine <Isaine@weldgov.com> Subject: Please Reply - PA FOR ROUTING: CW Core Non -Core 2021-22 Renewals B2100042 (CMS Various) Importance: High Please advise if you approve recommendation. Thank you! Karla Ford g Executive Assistant & Office Manager, Board of Weld County Commissioners 1150 O Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kford@weldgov.com :: www.weldgov.com **Please note my working hours are Monday -Thursday 7:00a.m.-5:00p.m.** 1 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND AMANDA HARTSHORN DBA CREATIVE NURSING LLC. This Agreement Amendment, made and entered into l `Q11" day of ‘`A 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Departn4ent of Human Services, hereinafter referred to as the "Department", and Amanda Hartshorn DBA Creative Nursing LLC., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Nurturing Program, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1437, approved on May 26, 2021. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement will end on May 31, 2022. • The Original Agreement was amended on: March 7, 2022 to reflect contractor's name change from Amanda Hartshorn to Amanda Hartshorn DBA Creative Nursing LLC. April 27, 2022 to extend the term date through May 31, 2023. The Amendment is identified by the Weld County Clerk to the Board of County Commissioners as document number 2021-1437. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Section 17 of the Agreement, Notice Amanda Hartshorn, RN, MSN 33681 County Road 13 Windsor, Colorado 80550 • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST:"" 1' BY: Deputy Cler COUNTY;, BOARD OF COUNTY COMMISSIONERS WELD COUNTY „COLORADO K. James, Chair MAY 16 2022 CONTRACTOR: Amanda Hartshorn DBA Creative Nursing LLC. 33681 County Road 13 Windsor, Colorado 80550 By: Amanda Hartshorn (May9, 2022 17,15 MDT) Amanda Hartshorn, RN, MSN May 9, 2022 Date: Contract Form New Contract Request Entity Information Entity Name* CREATIVE NURSING LLC Entity ID* x^00045193 Contract Name* CREATIVE NURSING LLC (AGREEMENT AMENTMENT 3) Contract Status CTB REVIEW ❑ New Entity? Contract ID 5810 Contract Lead* APEGG Contract Lead Email apegg@weldgov.com: cobbx xlkfwweldgov.com Contract Description * CONSENT: AMENDMENT TO UPDA I t ADDRESS. BID# B2100042 Contract Description 2 PA IS BEING ROUTED THROUGH THE NORMAL PROCESS. ETA TO CTB 5 19 22. Contract Type AMENDMENT Amount., $0.00 Renewable* NO Automatic Renewal Department HUMAN SERVICES nt Email CM- HumanServicese weldgov.co m Department Head Email CM-HumanServices- DeptHead.:weldgov,com County Attorney GENERAL COUNTY AI I ORNEY EMAIL County Attorney Email CM- COUNTYA I I ORNEY@WELDG OV.COM If this is a ren enter previous Contract ID If this is part of a MSA enter MSA Contract ID Requested BOCC Agenda Date* 06 01,,2©22 Parent Contract ID 20211437 Requires Rnard Approval YES Department Project # Due Date 05'2812022 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04,'03,32023 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 05/11/2022 Final Approval ROCC Approved &)CC Signed Date ROCC Agenda Date 05,`16,=2022 Originator APEGC Committed Delivery Date Contact Type Contact Email Finance Approver CONSENT Expiration Date* 05/3112023 Contact Phone 1 Purchasing 05 1 1'2022 Finance Approved Date 05;`11:2022 Tyler Ref # AG 051622 Date Legal Counsel CONSENT Legal Counsel 05'11;2022 Contact Phone 2 d Date PRIVILEGED AND CONFIDENTIAL Cu n+va d I Di 57(o l MEMORANDUM DATE: March 29, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2021-22 Core/Non-Core Contracted Services B2100042 Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement Amendments for 2021- 22 Core/Non-Core Contracted Services B2100042. The Department entered into Agreements with various Child Welfare service providers through the 2021-2022 Request for Proposal (RFP), Bid Number: B2100042, identified as Tyler ID 2021-0307. These Agreements were issued for a period of three (3) years with the option to renew annually. The Department is requesting to renew the current Agreements with no changes for sixteen (16) providers reflected in the attached list. Agreements will be renewed for the second year for the period of June 1, 2022 through May 31, 2023. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. 1 recommend approval of these Agreement Amendments and authorize the Chair to sign. Perry L. Buck Mike Freeman, Pro -Tern Scott K. James, Chair Steve Moreno Lori Saine Approve Recommendation Schedule Work Session Other/Comments: Ph 4464 Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Page 1 ectoxbe.exi-fsp) Consevtl''c)c2YKia 4/a7/402wz1-►431 cxk / z — I ZZ PFtOOq 3 PRIVILEGED AND CONFIDENTIAL CMS Name Behavior Services of the Rockies Bid # B2100042 Bid Year 2021-22 Tyler ID 2021-1581 Centennial Mental Health B2100042 2021-22 2021-1579 Colorado State University B2100042 2021-22 2021-1583 4_ Hartshorn, Mandee dba Creative Nursing LLC B2100042 2021-22 2021-1437 Jones, Dr. Jacob B2100042 2021-22 2021-1470 Northern Colorado Counseling (Rascon, Christina) B2100042 2021-22 2021-1467 Northern Horizon Behavioral Health - Nikki Tolle B2100042 2021-22 2021-1436 Reaching Hope B2100042 2021-22 2021-1547 Reece, Alison B2100042 2021-22 2021-1438 Rocky Mountain Kids B2100042 2021-22 2021-1465 Sovereignty Counseling - Annette Brown B2100042 2021-22 2021-1439 Specialty Counseling & Consulting B2100042 2021-22 2021-1466 The Hope Initiative B2100042 2021-22 2021-1582 Tindall and Associates B2100042 2021-22 2021-1606 VitalCare B2100042 2021-22 2021-1469 Withers Whisper -Andrea Hall B2100042 2021-22 2021-1471 Pass -Around Memorandum; March 29, 2022 — CMS ID — Various Page 2 Karla Ford From: Sent: To: Subject: yes Lori Saine Weld County Commissioner, District 3 1150 0 Street PO Box 758 Greeley CO 80632 Phone: 970-400-4205 Fax: 970-336-7233 Email: lsaine@tiveldgov.com Website: www.co.weld.co.us In God We Trust Lori Saine Tuesday, March 29, 2022 11:34 AM Karla Ford RE: Please Reply - PA FOR ROUTING: CW Core Non -Core 2O21-22 Renewals B21OOO42 (CMS Various) Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Karla Ford <kford@weldgov.com> Sent: Tuesday, March 29, 2022 10:45 AM To: Lori Saine <Isaine@weldgov.com> Subject: Please Reply - PA FOR ROUTING: CW Core Non -Core 2O21-22 Renewals B21OOO42 (CMS Various) Importance: High Please advise if you approve recommendation. Thank you! Karla Ford Al Executive Assistant & Office Manager, Board of Weld County Commissioners 1150 O Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kford@weldgov.com :: www.weldgov.com :: **Please note my working hours are Monday -Thursday 7:00a.m.•5:00p.m.** 1 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND AMANDA HARTSHORN DBA CREATIVE NURSING LLC. This Agreement Amendment, made and entered into Z� 'day of vt 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Amanda Hartshorn DBA Creative Nursing LLC., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Nurturing Program, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1437, approved on May 26, 2021. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement will end on May 31, 2022. • The Original Agreement was amended on: March 7, 2022 to reflect contractor's name change from Amanda Hartshorn to Amanda Hartshorn DBA Creative Nursing LLC. The Amendment is identified by the Weld County Clerk to the Board of County Commissioners as document number 2021-1437. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This Agreement is being renewed for a second full year term, for the period of June 1, 2022 through May 31, 2023. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: ddrittA) D:CI BY: BOARD OF COUNTY COMMISSIONERS WELD ?OUNTY, COLORADO Deputy ClerkJames, Chair APR 2 7 2022 manda Hartshorn DBA Creative Nursing LLC. 820 Ponderosa Court Eaton, Colorado 80615 By: Amanda Hartshorn (Apr 20, 2022 13:42 MDT) Amanda Hartshorn, RN, MSN Apr 20, 2022 Date: 020021- P74.3 Contract Form New Contract Request Entity Information Entity Name* CREATIVE NURSING LLC Entity ID* AO0045193 Contract Name* CREATIVE NURSING LLC (AGREEMENT AMENDMENT PY 2022-23) Contract Status CTB REVIEW Contract Description * BID# B2100042. TERM 6 1 22- 5 ' 31 23. Contract Description 2 CONSENT: PA WAS SENT TO CTB ON: 3 30r 2022. Contract Type AMENDMENT Amount* 30.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.co rn Department Head Email CM-HumanServices- DeptHead v eldgov,com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY' WELDG O1r,COM If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID New Entity? Contract ID 5764 Contract Lead* APEGG Contract Lead Email apeggAweldgov.com;cobbx xlkAweldgov.com Requested BOCC Agenda Date* 05/25/2022 Parent Contract ID 2011437 Requires Board Approval YES Department Project # Due Date 05:21 2022 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date 04.03:2023 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Committed Delivery Date Expiration Date* 05 31 2023 Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Approver Purchasing Approved Date CONSENT 04 22;'2022 Approval Process Department Head JAMIE ULRICH DH Approved Date 04'2212022 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 04'27.2022 Originator APEGG Finance Approver CONSENT Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 04 22!2022 04:22;2022 Tyler Ref t AG 042722 aarrFvac+ 11245(L3q PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 1, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with Amanda Hartshorn DBA Creative Nursing LLC. Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement Amendment with Amanda Hartshorn DBA Creative Nursing LLC. Ms. Hartshorn is a Registered Nurse who provides a Nurturing Program through the Department's Division of Child Welfare under the Agreement know as Tyler ID 2021-1437. On January 5, 2022, Ms. Hartshorn successfully filed paperwork with the Secretary of State to become an LLC and received a new tax identification number. The Department is requesting to amend the current contract to reflect the change from Amanda Hartshorn to Amanda Hartshorn DBA Creative Nursing LLC. I do not recommend a Work Session. I recommend approval of this Amendment. Approve Recommendation Perry L. Buck Mike Freeman, Pro -Tern Scott K. James, Chair Steve Moreno Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; March 1, 22 — MS ID 40) CoylUyl,-fr Artag,.- o8/01/zZ ..S/7/° - Page71 1(1 31 4 0N3 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND AMANDA HARTSHORN DBA CREATIVE NURSING LLC. This Agreement Amendment, made and entered into —POI day of Oki( On 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Amanda Hartshorn DBA Creative Nursing LLC., hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Nurturing Program, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1437, approved on May 26, 2021. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: On January 5, 2022, Ms. Hartshorn successfully filed paperwork with the Secretary of State to become an LLC and received a new tax identification number. This contract is now amended to reflect that change from Amanda Hartshorn to Amanda Harsthom DBA Creative Nursing LLC. The County agrees to issue payment to the new LLC for services rendered and Ms. Hartshorn agrees to provide updated paperwork reflecting this change including proof of insurance. All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COtJNTY;, ATTES dderAtiV �f".:.f�_ BOARD OF COUNTY COMMISSIONERS WEL O TY, COLORADO BY Deputy Cle tt K. James, Chair MAR 0 7 2022 Amanda Hartshorn DBA Creative Nursing LLC. 820 Ponderosa Court Eaton, Colorado 80615 By: Amanda (Feb 24, 2022 18:17 MST, Amanda Hartshorn, RN, MSN Date: Feb 24, 2022 Contract Form New Contract Request Entity Information Entity Name* HARTSHORN, AMANDA Entity ID* g^00043381 ❑ New Entity? Contract Name* Contract ID HARTSHORN, AMANDA DBA CREATIVE NURSING LLC 5634 (AMENDMENT I) Contract Status CTB REVIEW Contract Lead* APEGG Contract Lead Email apegg weldgov.com:cobbx xlkrweldgov.com Parent Contract ID 20211437 Requires Board Approval YES Department Project I Contract Description* THE PROVIDER AMANDA HARTSHORN IS NOW DBA CREATIVE NURSING LLC. EFFECTIVE JANUARY 5, 2022. Contract Description 2 PA IS BEING ROUTED THROUGH THE NORMAL PROCESS ETA TO CTB: 3 3122. Contract Type* AGREEMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant ICA Department HUMAN SERVICES Department Email CM - H umanServicesgiweldgov.co m Department Head Email CM -Hu man Services- DeptHeadnreldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEYWELDG OV.COM Requested BOCC Agenda Date* 03x'09;'2022 Due Date 03/05,2022 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04;01 2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Committed Delivery Date Expiration Date* 05 31/2022 Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Approver Purchasing Approved Date CONSENT 02 /28 2022 Approval Process Department Head JAMIE ULRICH DH Approved Date 02/2812022 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 03,`07; 2022 Originator APEGG Finance Approver CONSENT Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 02/28/2022 02'28,2022 Tyler Ref # AG 030722 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND AMANDA HARTSHORN This Agreement, made and entered into thy((# day of Board of Weld County Commissioners, on behalf of the Weld County Dep referred to as the "Department" and Amanda Hartshorn, hereinafter referred 77,41g..4 2021, by and between the ent of Human Services, hereinafter as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number B2100042 which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Nurturing Program. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 2021, upon proper execution of this Agreement and shall expire May 31, 2022, unless sooner terminated as provided herein. The agreement is for a period of three years. However, the agreement must be renewed by both parties, in writing, on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, Contractor's Response to Request for Proposal and Exhibit C, Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team (HS-CWOualitvAssurance(ujweldsov.com). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7th of the month, following the month of service, utilizing billing forms required by the Department. Contractor agrees to utilize the Client Verification Form for all scheduled and unscheduled face-to-face services with the exception of home studies and monitored sobriety testing. Contractor agrees that original complete Client Verification Forms are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received c& I C4 ) 2021-1437 #6oQ3 after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 60 -day deadline may result in termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 4. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Financial Management 2 At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMG Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule: a. If services are funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and - Title VII of the Civil Rights Act of 1964; and the Age Discrimination in Employment Act of 1967; and - the Equal Pay Act of 1963; and - the Education Amendments of 1972; and - Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the 3 Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, contractors and sub -contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services, Office for Civil Rights. c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is determined by the Department. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under 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; and - 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 this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, or local) terminated for cause or default. e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E - Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides 4 information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new employee to perform work under the contract, affirm that Contractor has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contractor shall deliver to the Department, a written notarized affirmation that it has examined the legal work status of such employee and shall comply with all of the other requirements of the State of Colorado program. If Contractor fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for breach, and if so terminated, Contractor shall be liable for actual and consequential damages. f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contractor receives federal or state funds under the contract, Contractor must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24- 76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5- 103 prior to the effective date of the contract. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 3(d) of this Agreement. 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable to the Contractor's business, at its own expense, and maintain for the duration of the work, insurance coverage listed in this agreement. The Board of County Commissioners of Weld County and its Officers/Employees shall be named as additional insured. 5 a. General Requirements: Contractors must secure, at or before the time of execution of any agreement or commencement of any work, the following insurance covering all operations, goods or services provided pursuant to this request. Contractors shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall contain a valid provision or endorsement stating "Should any of the above -described policies by canceled or should any coverage be reduced before the expiration date thereof, the issuing company shall send written notice to the Weld County Director of General Services by certified mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such cancellation or reduction unless due to non-payment of premiums for which notice shall be sent ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the Department must be notified by the Contractor. Contractor shall be responsible for the payment of any deductible or self -insured retention. The Department reserves the right to require Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or self -insured retention to guarantee payment of claims. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: i.Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent, covering premises operations, fire damage, independent Contractors, products and completed operations, blanket contractual liability, personal injury, and advertising liability with minimum limits as follows: - $1,000,000 each occurrence; - $2,000,000 general aggregate; - $50,000 any one fire; and - $500,000 errors and omissions. iii.Automobile Liability: Contractor shall maintain limits of $1,000,000 for bodily injury per person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property damage applicable to all vehicles operating both on County property and elsewhere. iv.Additional Provisions: Policies for all general liability, excess/umbrella liability, liquor liability and pollution liability must provide the following: If any aggregate limit is reduced by twenty-five percent (25%) or more by paid or reserved claims, Contractor shall notify the Department within ten (10) days and reinstate the aggregates required; Unlimited defense costs in excess of policy limits; Contractual liability covering the indemnification provisions of this Agreement; A severability of interests provision; Waiver of exclusion for lawsuits by one insured against another; A provision that coverage is primary; and A provision that coverage is non-contributory with other coverage or self-insurance provided by the Department. 6 v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and professional liability policies, if the policy is a claims -made policy, the retroactive date must be on or before the contract date or the first date when any goods or services were provided to the Department, whichever is earlier. c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at or before the time of execution of this Agreement, and shall keep in force at all times during the term of the Agreement as the same may be extended as herein provided, a commercial general liability insurance policy, including public liability and property damage, in form and company acceptable to and approved by said Administrator, covering all operations hereunder set forth in the related Bid or Request for Proposal. d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance agent or broker and shall have its agent or broker provide proof of Contractor's required insurance. The Department reserves the right to require Contractor to provide a certificate of insurance, a policy, or other proof of insurance as required by the County's Risk Administrator in his sole discretion. e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability, liquor liability, and inland marine, Contractor's insurer shall name County as an additional insured. f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation rights against County. g. Subcontractors: All subcontractors,.independent contractors, sub -vendors, suppliers or other entities providing goods or services required by this Agreement shall be subject to all of the requirements herein and shall procure and maintain the same coverages required of Contractor. Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or other entities as insureds under its policies or shall ensure that all subcontractors maintain the required coverages. Contractor agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors, suppliers or other entities upon request by the Department. A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage: Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and $2,000,000 aggregate limit for all claims. 10. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the 7 Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 13. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human 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: - Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. - 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 Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. - Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s). 8 For Department: For Contractor: Heather Walker, Child Welfare Director Amanda Hartshorn, RN, MSN 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich, Director P.O. Box A Greeley, CO 80632 (970) 400-6510 18. Litigation For Contractor: Amanda Hartshorn, RN, MSN 820 Ponderosa Court Eaton, Colorado 80615 (970) 980-9506 Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. 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 Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement 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 and nothing 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 receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more 9 sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties/Conflict of Interest No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department when the Contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement, Contractor shall not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all 10 such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcoitractor, if any, that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit A, provide proof thereof when requested to do so by County. 28. Eitire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence 11 and judgment provided by highly competent individuals and entities that perform services of a similar nature to those described in this Agreement including Exhibits A, B, C, and D. 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. &&24-18-201 et seq. and &24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 36. Attorney's Fees/Legal Costs 12 In the event of a dispute between the Department and Contractor, concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. 37. Ownership All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of the Department. In addition, all reports, documents, data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the Department. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of the Department. 38. Interruptions Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 39. Severability If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: Weld Co ty Clerk to the Board WELD COUNTY, COLORADO BOARD OF COUNTY COMMISSIONERS By: Deputy Clerk to tip Board • 13 Steve Moreno, Chair MAY 2 6 2021 CONTRACTOR: Amanda Hartshorn 820 Ponderosa Court Eaton, Colorado 80615 (970) 980-9506 By: Date: Amanda Hartshorn (May 19, 2021 09:11 MDT) Amanda Hartshorn, RN, MSN May 19, 2021 oZoo2/ --/So7 EXHIBIT A WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) 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Exhibit B Contractor's response to the Request for Proposal Exhibit B contains the following documents: Attachment B — Provider Information Form (PIF) • Attachment C — Proposal Attachment D — Staff Data Sheet • Certificate of Insurance (COI) I ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES - PROVIDER INFORMATION FORM AGENCY INFORMATION Amanda Hartshorn Ama nda Hartshorn 970-980-9506 Ext.: hartshorn7@gmaii.com Primary Contact Email: 820 Ponderosa Court Agency Location Address r.sitreet, oty, szate ros): Public Company Eaton, CO 80615 lion -Profit Trails Provider ID (if known): Registered Nurse Title: g Fax Number ao-dfg;t); Web Address: Private for Profit Send Referrals for Service to: Amanda Hartshorn eferzalContact Name: 970-980-9506 Number (10 dttp Registered Nurse Emaa: hartshorn7@gmail.com Billing Contact ngcort[adlName; Amanda Hartshorn 970-980-9506 iliing Phone Number (10-t;gid; Registered Nurse Title: �' • CERTIFICATION • I certify that the services proposed for intendeduse by the Weld County Departmen t specifications it has so indicated in this bid form, 9 further affirm intent, behalf of the Weld County Department of t? The Board of Weld County Commissioners r accept the bid, or part of a bid, that, in the opinion State of Colorado. The Board of Weld County Corgi where the bids are competitive in price and • Authorized Rep. Full Name: Amanda ! Authorized Rep: E hartshorn7 i Authorized Rep. Address Greet city, s in the best to et est f ₹ie`Boa d an`d of `the County of Weld, gene i)144 eno to resident Weld County bidders in ail cases Registered Nurse TT CHM ENT C PR SALi Please type your answers in the b ;_ xes below or check the appr * priate OK. hiders Leg Pr gram Area: Na m e : SECT N 1— Proe e ran Pro ram r e fig n Amanda Hartshorn, RN MSN Home- ased Interventi n Program Areas are listed in column 1 of the table I ft r Prop s I starting on page 13 (f, cated en Item XI i f the Request Number of services tiered on this Attachment C (max 5): You may complete;# nother Attachment C ii you have more than 5 3 curriculum, a rr state nt■■iR�;n SECT a PN 2 o Service p ease urn Names) *ger number afferent *f and dfrect Info! leLU7eLs0 ser at?on ice W monthly hours. L'�acka es L lust Service 201a 2.1b 2.1c 2.1d 2.1e 2.1f 201g 2.1h Mt t Modalities, e #1 service Name: r '.MF_cCJVattes r hill specific is Case Management/Educati n teas used in delivery *f service (DO NIT list company histtry° DO use bullet points): Utilizing RN RN RN RN Collaboration clearly medical RN RN RN N- will will will will will well will will provide utilize .else pn work understood r provide be Evidence information Beet/staff un,sble setup vide credi0.:le immediate with with education hands Based and family to medical (modify with and provide facilitate on resources Research, to independently casework regarding response understand providers meth nursing •tngoing appointments such ids skilled and rs medical and and of as nursing as years and presenting requested. Children's support other navigate educati of diagn*sis and meet support experience: professionals nn to the medical info• Hospital records only clients healthcare (ie. and rrmation by Hcsme treatment. reviews and needs directing OnlinE=, to to) family, system. Health as of the meet families Mayo and requested. goals as client Care educating Clinic necessary, so and that Services). etc. ensure they as needed via education can caregivers phone understand im to enhance �:.r in -person is ordered done the educatio support .accurately complex interventions. ,. and Anticipated administrative frequency time, of direct o p erhead, service or time travel with time (he. the 4 client/family hours/week). per If the week, service not including has levels, be professional specific for staffing each level: time, 4-8 hours/\Aieek Anticipated duration of service (roe. 3-4 months: 30-90 days with optic n to extended upon request by either party and apprr*val by 'NHS Ti hre - (3), sr mare, specific goals of the s;-°rvice (DO us§.. bull -it points): informatitn Client Provider RN RN Client supptH cN understanding will will will will will have have . prom will have be to be reviewed collabtrated able te a DHS and a a dear Liais to caseworkers, independently safe stability. understanding ,, all hoar between Medical with other environment, professionals, providers, documentation navigate regarding providers establish parents, the and their and healthcare provided relevant professionals complex long foster -tern and/or pare; system family medical ad its, to short obtained members. ensure and and needs -terms be the all aware through and Dep the goals self rtment. needs (of -care. research available to achieve if Tent and are resources medical pr -tided met needs for such additional Three (3), or mie, specific outcc.mes of service. Teach Positive- Establishment Understanding Establish 'medical -back feedback an needs of environment education of of to from healthy, [medical decrease/ regarding providers, supportive, documentation where eliminate comprehension parents, family trusting any can child foster reviewed function relati:r:nships pr*tection parents, or medic by independently care al or the with team, issues needs. families dr`partment within family, within the and and navigating home. regarding professionals. the child the s"rvices (if developmentally healthcare provided. system appr and *priate). meeting Target population of the service, includin , age and gender: Refrrrrals provided.' as submitted by DHS, no agr restrictions, or limitations. (Home Health Care hands on services will not be Languages service is available hi (please list proficiency and if interpreter services are availabl ). English Medicaid eligibility — list whether the service is eligible for Medicaid in .whole or in part: Not eligible REV. NOV 2020 1 TT CH M ENT C PROPOSAL Service #2 Na e Nursing Assessments and * bservati • ns — Face to Face H me Based Services 2.2a Mdalities, curriculum, to r ils used in delivery of service (DO NOT list company history; D i use bullet points): FC will provide in -home sup.rt t* clients included in referrals received by the Department RN will utilize inf*rmation provided by the Department and other professic• nals, in addition t*, the information gathered from the client and family assessor-?nt to determine the medical and mental healthcare ncteds of the client. RN will provide ongoing documentation and/or communication of objective observations and interactions with the Client to the caseworker via phone or email. RN will setup and/or attend medical appointments acting as a liais.n between Client, caregiver, and DHS staff. Rn will establish long-term and short-term goals, create an initial health service plan, and obtain current provider / service info rmation pertinent to medical and mental h alth needs. RN will provide demonstration and walk caregivers through preforming ordered medical tasks safely and competently (example: cleaning G -tube). RN will provide hares . n nursing skilled educatin only by directing and educating caregivers on ordered interventions. RN will be unable to provide Ing.Ding nursing support (ie. Home Health Care Services). 2.2b Anticipated frequency of direct s - rvice time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.2c 2-1® hours/week nticipated duration of service (i.e. 3-4 months): 1-90 days with option to extended upon request by either party and approval by DHS Lid Three(3),orm re, specific goals of the service (DO use bullet points): Face to face / Virtual medical assessment/clinical consultation on cases, collaborate with caseworkers and medical professionals, and education of medical information with return demonstration of understanding by child, family or staff. Collaboration with providers and other professionals to meet established goals Hands on education to promote independent navigation of healthcare system. Attend appointments as determined necessary to ensure understanding of information provided by providers, to work towards fostering independent navigation of the healthcare system. Caregivers will demonstrate competence in performing ordered interventions by provider. 2.2e Three (3), or more, specific outcomes of service: Assess for medical issues that may be creating child protection concerns and establishment of long-term and short -terms goals with monthly reassessment and modification as determined necessary. Obtain feedback from child, family, or staff regarding collaboration on cases. Ensure understanding by return demonstration or teach -back of medical diagnosis and treatment as directed by provider. Promote a healthy environment where medical and mental healthcare needs are understood, decreasing /eliminating child protection issues. Caregivers will be able to teach -back RN with master level of ordered interventions by provider. 2.2f Target population of the service: Referrals as submitted by DHS, no age restrictions, or limitations. (Home Health Care hands on services will not be provided.) 2.2g Languages service is available in (please list proficiency and if interpreter services are available): English 2.2h Medicaid eligibility e list whether the service is eligible f r Medicaid in whole or in part: Not Eligible Service #3 Name: Consultati n 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Utilizing Evidence Based Research, and years of experience: RN will provide educati,•-n regarding medical diagnosis and treatment. RN will utilize credible resources such as Children's Hspital Online, May, Clinic etc. as needed tenhance education. RN will provide immediate response and support to DHS Caseworkers and staff, as necessary, via phone or in-pers,>n. RN will work with DHS Caseworkers and staff to undrstand and meet medical needs of the client. RN will meet/staff with caseworkers as requested. RN will be present in DHS Offic- to provide ongoing staffing and support / consultation on medical aspects of cases. 2.3b Anticipated frequency •f direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, r travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Assess for medical issues that may be creating child protection concerns and establishment of long-term and short -terms goals with monthly reassessment and modification as determined necessary collaboratively with DHS Caseworkers. REV. NOV 2020 2 ATTACHMENT®gipp ®SAL Obtain feedback from staff regarding collaboration on cases. Ensure understanding by return demonstration or teach -back of medical diagnosis and treatment as directed by provider. Promote a healthy environment where medical and mental healthcare needs are understood, decreasing /eliminating child protection issues. 2.3c Anticipated duration of service (Le. 3-4 months): Ongoing in office at DHS hours to provide support and staff cases with DHS Caseworkers. Hours to be determined and set as needed 0-40 per week. 2.3d Three (3), or more, specific goals of the service (DO use bullet points): In Person face to face at the DHS office, consultation on cases, collaborate with caseworkers and medical professionals, and education of medical information with return demonstration of understanding by staff. Collaboration with providers and other professionals to meet established goals. Hands on education to promote independent navigation of healthcare system. Review attended appointments with DHS Caseworkers to ensure seamless understanding of outcome of appointments. 2.3e Three (3), or more, specific outcomes , f service: Assess for medical issues that may be creating child protection concerns and establishment of long-term and short -terms goals with monthly reassessment and modification as determined necessary. Obtain feedback from staff regarding collaboration on cases. Ensure understanding by return demonstration or teach -back of medical diagnosis and treatment as directed by provider. Promote a healthy environment where medical and mental healthcare needs are understood, decreasing /eliminating child protection issues. 2.3f Target population of the service: Referrals as submitted by DHS, no age restrictions, or limitations. (Home Health Care hands on services will not be provided.) 2.3g Languages service is available in (please list proficiency and if interpreter services are available): English 2.3h Medicaid eligibility ® list whether the service is eligible for Medicaid in whole r in part: Not Eligible Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery f service (DO NOT list company history; DO use bullet p ints): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (Le. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (Le. 3-4 months): 2.4d Three (3), or more, specific goals of the service (DO use bullet points): 2.4e Three (3), or more, specific outcomes of service: 2.4f Target population of the service: 2Ag Languages servic - is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility ® list whether the service is eligible f r Medicaid in whole or in part: Service #5 Name: 2.5a Modalities, curriculum, tools used in del ery of service (DO NOT list co pany history; DO use bullet points): 2.5b Anticipated frequency of direct service time with the client/family per eek, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (Duse bullet points): REV. NOV 2020 3 ATTACHMENT C - PROPOSAL 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part Section 3 — Service Access and Transportation 3.1 Will you charge Weld County for transporting clients or mileage? Check one: 3.2 Will you conduct services in a client's home or in the community? Check one: 3.3 Will you transport clients to and/or from services? Check one: YES 3.4 How many miles are you willing to travel round trip? List a specific number of miles. 3.5 When you calculate mileage, what is your starting point address? ■ YES ■ NO YES ■ NO NO 75 Miles 820 Ponderosa Court, Eaton, CO 80615 SECTION 4 - SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. • For hourly rates complete section(s) 4.1-4.5. • For monthly rates complete section 4.6. • For Home study providers complete section 4.7. • For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: Case Management / Education 4.1a In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate: $ Amount 105 105 105 95 75 0.55 Unit Type per Hour per Hour per Hour per Hour per No Show per Mile No. of miles included in rate: 20 No. of miles included in rate: 20 This is paid after the miles listed above. miles miles 4.2 Hourly Service #2 Name: Nursing Assessments and Observations — Face to Face Home Based Services 4.2a In-Office/Video: 4.2b In -Office with Transportation: 4.2c In -Home or Community: 4.2d FTM, TDM, Prof. Staffing: 4.2e No show: 4.2f Mileage rate: $ Amount 130 130 130 95 75 0.55 Unit Type per Hour per Hour per Hour per Hour per No Show per Mile No. of miles included in rate: No. of miles included in rate: 20 20 This is paid after the miles listed above. miles miles 4.3 Hourly Service #3 Name: Consultation 4.3a In-Office/Video: 4.3b In -Office with Transportation: $ Amount 105 105 Unit Type per Hour per Hour No. of miles included in rate: 20 miles REV. NOV 2020 4 TTACHMENT C ® P : POSAL 4.3c In -Home or Community: 4.3d FTM, TDM, Pr • f. Staffing: 43e No sh:• w: 4.3f ileage rate: 105 95 75 035 per H::ur per Hour per No Sh per Mile w No. of miles included in rate: 20 This is paid after the miles listed above. miles 404 Hourly Service #4 Name: 4.4a In-Sffice/Video: 4o4b In -Office with Transportation: In -Home or Cmmunity: 4.4c FTM, TDM, Prof. Staffing: 4.4d Nt show: 4e4e Mileage rate: $ Amount Unit Type per Hour per Hour per Hour per H*ur per No Sh per Mile w N o. of miles included in rate: No, of miles included in rate: This is paid after the miles listed above. miles miles 4.5 Hourly Servic #5 Name: 4.5a In-Office/Video: 4.5b In -Office with Transportation: 4.5c In -Home or Community: 4.5d FTM, TDM, Prof. Staffing: 4.5e N=:, show: 4.5f Mileage rate: Am Unit Type per Hour per Hour per Hour per H# -gar per No Show per Mile N of miles included in rate: N o. of miles included in rate: This is paid after the miles listed above. miles miles 4.6 Monthly Service Rates (each level must be listed): 4.6a Service Name with Level Rate per Month No. of Direct Service Hours: 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4.7 H (1. me Study Providers ® List your rates in the box below. 4.8 Monitored Sobriety Providers — List your rates in the box below. Prs.vider special notes: REV. NOV 2020 5 ATTACHMENT D - STAFF DATA SHEET Bidder Must List All Staff Who Will Administer the Proposed Service(s) BIDDER'S LEGAL NAME (As it appears on the W-9): AGENCY CONTACT: Amanda Hartshorn Amanda Hartshorn PHONE NUMBER970-980-9506 EMAIL: hartshorn7@gmail.com PROPOSED SERVICE(S): Case Management / Education Nursing Assessment / Observation - Face to Face Home Based Services Consultation Legal Last Name I. Middle Initial Hartshorn L 11111111 Previous Legal Last Name (If applicable) Kohl Legal First Name Amanda Service Type All of the above Licensure/ Credentials RN, MSN DORA # (If applicable) RN.o189873 CHILD WELFARE REQUEST FOR PROPOSAL 2021-22 - VARIOUS SERVICES BID NO. B2100042 mnso 12/29/20 Amanda L Hartshorn 820 Ponderosa Ct Eaton, CO 80615-3558 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034-3278 Phone:1-800-247-1500 Fax:1-800-758-3635 Website:www.nso.com Dear Amanda L Hartshorn: Enclosed is the replacement certificate of insurance that you requested. If you have any questions or need assistance, please call us toll free at 1-800-247-1500. Our Customer Service Representatives are available weekdays from 8:00 a.m. to 6:00 p.m., EST. Sincerely, Customer Service Enclosure Q032 Dedicated To Serving The Insurance Needs of Nurses Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc.; (AR 244489); in CA & MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services Inc.; in CA, Aon Affinity Insurance Services, Inc., (0O94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency. ANA HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP Certificate of 3(tt5ttrance OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM LIflSO Print Date: 12/29/2020 The application for the Policy and any and all supplementary information, materials, and statements submitted therewith shall be maintained on file by us or our Program Administrator and will be deemed attached to and incorporated into the Policy as if physically attached. PRODUCER BRANCH PREFIX POLICY NUMBER POLICY PERIOD From: 03/19/21 to 03/19/22 at 12:01 AM Standard Time 018098 970 HPG 0646711593 Named Insured and Address: Program Administered by: Amanda L Hartshorn 820 Ponderosa Ct Eaton, CO 80615-3558 Medical Specialty: Code: Registered Nurse 80964 Excludes Cosmetic Procedures Nurses Service Organization 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034 1-800-247-1500 www.nso.com Insurance Provided by: American Casualty Company of Reading, Pennsylvania 151 N. Franklin Street Chicago, IL 60606 Professional Liability $ 1,000,000 each claim $ 6,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection Defendant Expense Benefit Deposition Representation Assault Includes Workplace Violence Counseling Medical Payments First Aid Damage to Property of Others Information Privacy (HIPAA) Fines and Penalties Media Expense Workplace Liability $ 25,000 per proceeding $ 25,000 aggregate $ 1,000 per day limit $ 25,000 aggregate $ 10,000 per deposition $ 10,000 aggregate $ 25,000 per incident $ 25,000 aggregate $ 25,000 per person $ 100,000 aggregate $ 10,000 per incident $ 10,000 aggregate $ 10,000 per incident $ 10,000 aggregate $ 25,000 per incident $ 25,000 aggregate $ 25,000 per incident $ 25,000 aggregate Workplace Liability Fire & Water Legal Liability Personal Liability Total $ 545.00 Included in Professional Liability Limit shown above Included in the PL limit shown above subject to $150,000 aggregate sublimit $1,000,000 aggregate Base Premium $545.00 Premium reflects Self Employed , Full Time Policy Forms and Endorsements (Please see attached list of policy forms and endorsements) Chairman of the' Board Secretary Keep this Certificate of Insurance in a safe place. It and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. To activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Coverage Change Date: CNA93692 (11-2018) Endorsement Date: Master Policy: 188711433 © Copyright CNA All Rights Reserved. POLICY FORMS & ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability policy. COMMON POLICY FORMS & ENDORSEMENTS FORM # G -121500-D (04-08) G -121503-C (07-01) G -121501-C (07-01) CNA94164 (11-18) G -145184-A (06-03) G -147292-A (03-04) GSL15563 (02-10) GSL15564 (10-09) GSL15565 (03-10) GSL17101 (02-10) GSL13424 (05-09) CNA80051 (09-14) CNA80052 (10-14) G -123846-005 (07-01) CNA81753 (03-15) CNA81758 (03-15) CNA82011 (04-15) CNA89027 (10-17) CNA79575 (07-14) CNA89026 (05-17) G -123828-B (07-01) G -141231-A (07-01) FORM NAME Common Policy Conditions Workplace Liability Form Occurrence Policy Form Amendment Definition of Claim Endorsement Policyholder Notice - OFAC Compliance Notice Policyholder Notice - Silica, Mold & Asbestos Disclosure Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion Healthcare Providers Professional Liability Assault Coverage Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies Services to Animals Amended Definition of Personal Injury Endorsement Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement Colorado Cancellation and Non -Renewal Coverage & Cap on Losses from Certified Acts Terrorism Notice - Offer of Terrorism Coverage & Disclosure of Premium Related Claims Endorsement Entity Exclusion Endorsement Exclusion of Cosmetic Procedures Media Expense Coverage Certificate Holder Additional Insured Healthcare Entity PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax. As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been applied to your insurance premium and is separately itemized on the Declarations page or billing instrument attached to your policy, as required KRS. §136.392. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association - 2012 Regular Assessment. Form #:CNA93692 (11-2018) Named Insured: Amanda L Hartshorn Master Policy #: 188711433 Policy #: 0646711593 © Copyright CNA All Rights Reserved. HEALTHCARE PROVIDERS PROFESSIONAL LIABILITY COVERAGE PART ENDORSEMENT Additional Insured — Healthcare Professional or Entity In consideration of the additional premium paid, and subject to the Professional Liability limit of liability shown on the certificate of insurance, it is agreed that the PROFESSIONAL LIABILITY COVERAGE PART is amended as follows: The person or entity named below (the "additional insured") is an insured under this Coverage Part but only as respects its liability for your medical incidents and solely to the extent that: 1. a professional liability claim is made against you and the additional insured; and 2. in any ensuing litigation arising out of such claim, you and the additional insured remain as co- defendants. In no event is there any coverage provided under this policy for a medical incident that is the direct liability of the additional insured. Additional Insured: Board of County Commissioners Weld Count & it's Officers & Employees 1150 O Street Greeley, CO 80631 This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown below. All other provisions of the policy remain unchanged. Must Be Completed ENDT. NO. POLICY NO. 01 646711593 Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy ISSUED TO ENDORSEMENT EFFECTIVE DATE Amanda Hartshorn 03/19/2021 G -141231-A (07/2001) Page 1 of 1 PROFESSIONAL LIABILITY INSURANCE ENDORSEMENT Agreement to Provide Notice of Cancellation In consideration of the premium paid, it is agreed that if the policy to which this endorsement is attached is cancelled before the expiration date, we will endeavor to mail notice to the person or entity named below. However, failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives. Person or Entity Name and Address: Weld County 1150 O Street Greeley, CO 80631 This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown below. All other provisions of the policy remain unchanged. Must Be Completed ENDT. NO. POLICY NO. 01 646711593 Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy ISSUED TO ENDORSEMENT EFFECTIVE DATE Amanda Hartshorn 03/19/2021 G -123828-B (7/2001) Page 1 of 1 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Home Based Intervention, as referred by the Department, and Case Consultation to Department staff, as needed. 2. All services will be provided by Mandee Hartshorn, an experienced Registered Nurse (RN). 3. Contractor will provide case consultation services and case management to the Department. Services will include: i. Evidence Based Research, and professional experience. ii. Education regarding medical diagnosis and treatment. iii. Utilization of credible resources such as Children's Hospital Online and Mayo Clinic as needed to enhance education. iv. Setup and facilitation of home visit or medical appointments and record reviews. v. Meeting with Department staff and caseworkers regarding specific cases to determine needs and goals. vi. Ongoing documentation and/or communication of objective observations and interactions with the client to the caseworker via phone or email. vii. Contractor will serve as a liaison between the client, caregiver and the Department for the purpose of setting up and/or attending medical appointments. viii. Health Service Plan. Contractor will work with Department, other professionals, client, and caregiver to create an initial Health Service Plan, and will obtain current provider and service information pertinent to medical and mental needs. b. Anticipated Frequency of Services: i. Established ongoing office hours at the Department as needed. c. Anticipated Duration of Services: i. Services shall be for the term of the Agreement unless otherwise modified per Paragraph five (5) of the Agreement. d. Goals of Services: i. Collaboration with Department staff to meet established goals. ii. Education of Department staff to gain a better understanding of medical information and needs of identified clients. iii. Education of Department staff and caregivers to better assist caregivers in navigating the healthcare system and understanding medical information. iv. Case management support to the Department and client. e. Outcomes of Services: i. Assessment of case -specific medical issues that may be creating child protection issues. ii. Establishment of short-term and long-term goals for each identified case. iii. Increased understanding of medical information and healthcare system by Department staff, allowing Department staff to better assist caregivers in mitigating or eliminating child protection issues. f. Target Population: i. All Department staff. ii. All clients as referred by Department. g. Language: i. English. 1 h. Medicaid Eligibility: i. This service is not Medicaid eligible. Service Access and Transportation: i. Contractor does not provide transportation. ii. Services will be primarily accessed onsite at the Department but may also be accessed outside of the Department at a mutually agreed upon location. Contractor may also be accessed via phone, email, and virtual platform. 4. Contractor will provide Home -Based Services, as referred by the Department, to include Education, Nursing Assessments and/or Observation. Services will include: i. Information gathering. Information will be collected from the Department, other professionals, the client, and the caregivers to the determine medical and mental health care needs of the client. Contractor will work collaboratively with all parties to gather and review all necessary information. ii. Goal setting. Short-term and long-term goals will be established pertinent to medical and mental health needs. iii. Health Service Plan. Contractor will work with Department, other professionals, client, and caregiver to create an initial Health Service Plan, and will obtain current provider and service information pertinent to medical and mental needs. iv. Hands-on Demonstration. Contractor will provide skilled hands-on demonstration to caregivers regarding performance of ordered medical tasks in a safe and competent manner. Demonstration will include skilled nursing education around ordered interventions. Contractor will not provide ongoing nursing support such as Home Health Care Services. v. Contractor will provide hands on nursing skilled education by directing and educating caregivers on ordered interventions. Contractor will not provide ongoing nursing support such as Home Health Care Services. b. Anticipated Frequency of Services: i. Two (2) to ten (10) hours per week, based on needs of client. c. Anticipated Duration of Services: i. One (1) to ninety (90) days with option to extend upon request by either party and with approval of the Department. d. Goals of Services: i. Education of client and/or caregiver regarding client specific medical information to promote increased understanding and knowledge of information and needs. ii. Hands-on skilled nursing demonstration of ordered medical interventions to promote understanding and competency by client and/or caregiver. iii. Hands-on education of client and/or caregiver regarding navigation of the healthcare system to promote confidence and increase ability to navigate the system successfully. e. Outcomes of Services: i. Client and/or caregiver will demonstrate: 1. Increased knowledge and understanding of the client's medical information and needs, including self -care, ongoing medical needs and requirements for a safe environment. 2. Increased understanding and competency regarding ordered medical interventions through hands-on performance of interventions. Client will demonstrate safe, accurate and confident performance of interventions. 2 3. Increased confidence and ability to navigate the healthcare system independently and successfully, and confidence accessing additional resources as needed. 4. Decreased child protection issues mitigated through increased knowledge, understanding of client's medical issues, needs and ordered interventions. f. Target Population: All ages and genders. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor does not provide transportation. ii. Services will be provided in person in the client's home, unless otherwise approved by the Department. Terms 1. Contractor will respond to the Quality Assurance Team (HS-CWQualitvAssurance(aiweldgov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team HS - C WQualitvAssurance(a,weldSov.com. 3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 -hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(n,weldgov.com. 4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(a,weldgov.com immediately via email, to discuss service continuation. 5. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 3 6. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 7. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by the caseworker, their supervisor, or the Family Support and Visitation Center. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Quality Assurance Team, and the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the Client Verification Form. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 10. Contractor will notify the Quality Assurance Team HS-CWQualityAssuranceC weldgov.com of new staff who will manage and/or administer the services with the following information: a. b. c. d. e. Staff member name and contact information Education level/degree (if applicable) Licensure/credentials (if applicable) Department of Regulatory Authority (DORA) number (if applicable) Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 4 EXHIBIT D RATE SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2022. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Nurturing Program Rate Unit Type Service Name $105.00 Hour Case Management/Education $105.00 Hour Consultation $95.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professionals Staffing $0.55 Mile Mileage, for distances exceeding 20 miles from 820 Ponderosa Court, Eaton, Colorado 80615 $75.00 Each No Show $130.00 Hour Nursing Assessments & Observations 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. Contract Form New Contract Request Entity Information Entity Name* HARTSHORN, AMANDA Entity ID* 'x'00043381 New Entity? Contract Name* AMANDA HARTSHORN (CHILD PROTECTION AGREEMENT) Contract Status CTB REVIEW Contract Description* BID# 82100042. TERM: 6t1 /21-5(31 ,'22. Contract ID 4782 Contract Lead* APEGG Contract Lead Email apegg@weldgov.com; co bbx xlkweldgov.com Contract Description 2 MEMO WAS PRESENTED TO THE 8OCC BY PURCHASING ON 4 7'2021 TYLER ID: 2021-0307. Contract Type AGREEMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM - H uman Service sweldgov. co rn Department Head Email CM-HumanServices- DeptHeadslveldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COU NTYATTO RN EY dWELDG OV.COM If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Requested BOCC Agenda Date* 05:26/2021 Parent Contract ID 20210307 Requires Board Approval YES Department Project # Due Date 05;22.2021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04101/2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 05/20)2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05J26,+2021 Originator APEGG Committed Delivery Date Contact Type Finance Approver CONSENT Expiration Date 05/31 /2022 Contact Phone 1 Purchasing Approved Date 05x20/2021 Finance Approved Date 05120:2021 Tyler Ref AG 052621 Legal Counsel CONSENT Contact Phone 2 Legal Counsel Approved Date 05/20±2021 Hello