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Home My WebLink About20201375.tiffPRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 29, 2022 con+vc((�+ TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2020-21 Core/Non-Core Contracted Services B2000037 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 2020- 21 Core/Non-Core Contracted Services B2000037. The Department entered into Agreements with various Child Welfare service providers through the 2020-2021 Request for Proposal (RFP), Bid Number: B2000037, identified as Tyler ID 2020-0373. 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 eight (8) providers reflected in the attached list. Agreements will be renewed for the third year for the period of June 1, 2022 through May 31, 2023. The Human Services Advisory Comriission (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 Schedule Recommendation Work Session Perry L. Buck Mike Freeman, Pro -Tern Vh Scott K. James, Chair Steve Moreno Lori Saine YLI, Other/Comments: Pass -Around Memorandum; March 29, 2022 —_CMS ID Page 1 WZO i B1S 9 22, �Ol� PRIVILEGED AND CONFIDENTIAL 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 O 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 11:33 AM Karla Ford RE: Please Reply - PA FOR ROUTING: CW Core Non -Core 2020-21 Renewals B2000037 (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 10:44 AM To: Lori Saine <Isaine@weldgov.com> Subject: Please Reply - PA FOR ROUTING: CW Core Non -Core 2020-21 Renewals B2000037 (CMS Various) Importance: High Please advise if you approve recommendation. Thank you. Karla Ford , Executive Assistant & Office Manager, 1150 0 Street, P.O. Box 758, Greeley, :: 970.336-7204 :: kforda[7.weldgov.con **Please note my working hours are Board of Weld County Commissioners Colorado 80632 1:: www.weIdgov.com :: Monday -Thursday 7:00a.m.-5:00p.m.** 1 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND KPJ FIRST SERVICES, LLC This Agreement Amendment, made and entered into day of , 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Depa nt of Human Services, hereinafter referred to as the "Department", and KPJ First Services, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Home -Based Intervention, Home Studies and Relinquishment Counseling, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2020-1375, approved on May 11, 2020. 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, 2021. • The Original Agreement was amended on: • May 3, 2021 to extend the term date through May 31, 2022 and amend the Exhibit D, Rate Schedule. • The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2020-1375. • 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 third and final year, 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. aoa1 -// lt, KPJ First Services, LLC 1626 Plains Drive Eaton, Colorado 80615 /t,2 aIWawa hial� By: Ke[h Paul Wawrzyniak (lay 9,2022 11 1 MDT) Keith P. Wawrzyniak, Jr., Owner Date: May 9, 2022 New Contract Request Entity Information Entity Namet Entity ID ❑ New Entity? K?) FIRST SERVICES, LLC @00041915 Contract * K?} FIRST SERVICES LLC (AGREEMENT AMENDMENT PY 2022-23) Contract Status CTB R Contract Description * BID# 92000032. TERM 611 ; 22-531 123. Contract Description 2 CONSENT. PA WAS SENT TO CTB ON: 3130 2022. Contract Type AMENDMENT Amount $0.00 Renewable * NO Automatic Renewal Grant Department Email CM_ Fi manServices eldgOv.cO m Department Head - it CM-HunianServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYA ORNEY E LDC OV COM if this is a renewal er previous Contract It) If this is part of a MSA enter #454 Contract it) Contract Lead APEGG Contract Lead Email apegg@weldgov.com,c0bbx xleldg0v.c0m Requested80CC Aqenda Date * 05f25f2022 Parent Contract ID 2020135 Requires Board Approval YES Department Project # Due Date 05121+'2022 Will a work session with 8OCC be required?* NO Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in CnBase Contract Dates Effective Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 05/102022 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05116;2022 Originator APEGG Review Date 04 03 202 3 Committed Delivery Date Renewal Date Expiration Date* 05,-31,2023 Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Approved Date 0510:2022 Finance Approver Legal Counsel CONSENT CONSENT Finance Approved Date Legal Counsel Approved Date 05310x2022 05,/10/2022 Tyler Ref # AG 051622 Cr 1+(tt C+ PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: April 27, 2021 E0 *L1 Co89 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with KPJ First Services, 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 KPJ First Services, LLC. The Department entered into a Child Protection Agreement for services with KPJ First Services, LLC, identified as Tyler ID 2020-1375 on May 11, 2020. The Agreement is being amended to renew for a second year, for the period of June 1, 2021 through May 31, 2022 and to make changes to the Rate Schedule as noted below. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Rate ScheduleChanges: Home Base Intervention Virtutr 'sit- "'5.001hour Mentor $706-5.00/Hour (In -Office) $27065.00/Hour (Out -of -Office) $654-S.00Nisit (No show) .55/Mile (Mileage) For distance exc.erdirru twenty (20i miles from practitioner's office located at 928 13th Street. Greeley, CO 8031. Supervised Visitation $75.00/Hour (In-Office/Virtu ) 35.00/14our (Slavish I ntupictii` Therapeutic Supervised Visits $95&$.00(Hour (In-Office/Virtual,) $35.00f1jc it (Spanish Inter Teter) Relinquishment Counseling 35.00(How (Spanish Intelpre r Pass -Around Memorandum; April 27, 2021 - ID 4.4 Page 1 Ong-a &-: ?1t Ae' A CYS t0 3 ( a .��.3-a-� ao e)o -' 315 HBO09o7 PRIVILEGED AND CONFIDENTIAL I do not recommend a Work Session. I recommend approval of this Agreement Amendment, Approve Schedule Recommendation Work Session Other/Comments: Perry L. Buck Mike Freeman Scott K. James, Pro -Tern Steve Moreno, Chair Lori Saine Pass -Around Memorandum; April 27, 2021 — ID 4684 Page 2 s fy AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND KPJ FIRST SERVICES, LLC R7 This Agreement Amendment, made and entered into 3 day of 2021 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 KPJ First Services, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Home -Based Intervention, Home Studies and Relinquishment Counseling, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2020-1375, approved on May 11, 2020. 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, 2021. • 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, 2021 through May 31, 2022. 2. Exhibit D, Rate Schedule, is hereby amended as attached. • 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. tt�, COUNTY: ATTEST: ) �Glif/�/BOARD OF COUNTY COMMISSIONERS Weld un]ly Clerk to the B at WELD COUNTY, COLORADO By: Deputy Cler the oard a Moreno, Chair MAY 0 3 2021 KPJ First Services, LLC 1626 Plains Drive Eaton, Colorado 80615 /K/0 w�a��rialr By: KP Wawrzyniak (Apr 1'202111:51 MDT) Keith P. Wawrzyniak, Jr., Owner Date: Apr 13, 2021 2Zoo2O-/37�' EXHIBIT D RATE SCHEDULE 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 Home Studies Rate Unit Type Service Name $1,200.00 Each Full Home Study $200.00 Each Additional Adult $60.00 Hour Partial Home Study $550.00 Each Home Study Update $100.00 Each Additional Adult Home Study Update $0.55 Mile Mileage — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. $200.00 Each Spanish Interpreter Fee — Full Home Study $100.00 Each Spanish Interpreter Fee — Home Study Update Facilitation of Team Decision Makin (TDM) Meeting or High Conflict Family Team Meeting (FTM) Rate Unit Type Service Name $115.00 Hour Out -of -office $115.00 Hour FTM, TDM, Professional Staffing $50.00 Visit No-show Family Team Meeting (FTM) Rate Unit Type Service Name $95.00 Hour Out -of -office $95.00 Hour FTM, TDM, Professional Staffing $50.00 Visit No-show Home Based Intervention Rate Unit Type Service Name $125.00 Hour Out -of -office $65.00 Hour FTM, TDM, Professional Staffing $65.00 Visit No-show $75.00 Hour Virtual Visit $0.55 Mile Mileage — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. Mentoring Rate Unit Type Service Name $70.00 Hour In -Office $70.00 Hour Out -of -office $65.00 Hour FTM, TDM, Professional Staffing $65.00 Visit No-show $35.00 Hour Spanish Interpreter $0.55 Mile Mileage — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. Supervised Visitation Rate Unit Type Service Name $75.00 Hour In-OfficeNirtual $105.00 Hour Out -of -office $65.00 Hour FTM, TDM, Prof. Staffing $65.00 Visit No-show $35.00 Hour Spanish Interpreter $0.55 Mile Mileage — For distance exceeding twenty (20) miles from practitioner's office located at 928 13`h Street, Greeley, CO 80631. Therapeutic Supervised Visits Rate Unit Type Service Name $95.00 Hour In-Office/Virtual $125.00 Hour Out -of -office $65.00 Hour FTM, TDM, Professional Staffing $65.00 Visit No-show $35.00 Hour Spanish Interpreter $0.55 Mile Mileage — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. Relinquishment Counseling Rate Unit Type Service Name $95.00 Hour In -Office $150.00 Hour Out -of -office $65.00 Hour FTM, TDM, Professional Staffing $65.00 Visit No-show $35.00 Hour Spanish Interpreter $0.55 Mile Mileage — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. 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 Regiests 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. New Contract Request Entity Information Entity Nave* Entity ID* LI New Entity? IMP FIRST SERVICES, LLC A00041 915 Contract Name * KPI FIRST SERVICES, LLC (AGREEMENT AMENDMENT) Contract Status CTB REVIEW Contract Description * RID#R2000Q37TERM 6/1/21-5/31/22. Contract Description 2 CONSENT: PA "'AS SENT TO CTB ON 3/31/21. Contract ID 4684 Contract. Lead APEGG Contract Lead Email apeggct~,weldcovcom:cobPx xIk weldgov..coni Parent Contract ID 20201375 Requires Board Approval YES Department Project t Contract Type * Department Requested BOCC C Agenda Due Date AMENDMENT HUMAN SERVICES Date * 05,'22/2021 05x26 2021 Amount* Department Email 50.00 CM- Will a work session with BOCC be required?* Hun anServicesJl weldgov.co NO Renewable * m NO Does Contract require Purchasing Dept. to be included? Department Head Email Automatic Renewal CM-HurmanServices- DeptHead veldgov.cor Grant County Attorney GENERAL COUNTY IGA ATTORNEY EMAIL County Attorney Email CM- COUNTY"ATTORNEY 's ELDG OV,COM ti this is a renewal enter prevics Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Nur fiber and Master Services Agreement Number should be left blank if those contracts are not in OnRase Contract Dates Effective Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 04/19i2021 Final Approval RoCC Approved t i m SQCC Agenda Date 0503/2021. Originator APEGG Review Date 04:01<20.22 Committed Delivery Date Renewal Date Expiration Date* 05/31 2O22 Contact Type Contact Email Contact Phone 1Contact Phone Purchasing Approved Date 04:19/2021 Finance Approver CONSENT Finance Approved Date 0419/2021 Tyler Ref AG 050321 Legal Counsel CONSENT Legal Counsel Approved Date 04/19'2021 ( +me -r Mb 4 3535 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND KPJ FIRST SERVICES, LLC This Agreement, made and entered into the day of '- ' =' 2020, 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 KPJ First Services, LLC, hereinafter referred to 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 B2000037, 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 Child Welfare Administration or other funding to the Department for Facilitation, Home -Based Intervention, Home Studies and Relinquishment Counseling. 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, 2020, upon proper execution of this Agreement and shall expire May 31, 2021, 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. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). No other Department staff or other party to the case may authorize services or modifications to services. c.c. HSD Gnk?jait 2020-1375 O5 r I I r HROO9a 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 one-time services (ex. home studies, evaluations and monitored sobriety testing). Contractor agrees that original complete Client Verification Forms with original signatures are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received 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. evaluations, 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 Manaeement 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 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. 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 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. 4 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 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 5 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. 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. 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. C1 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. 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 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). For Department: For Contractor: Heather Walker, Child Welfare Division Head Keith Wawrzyniak Jr., Owner 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) 400-6581 18. Litigation For Contractor: Keith Wawrzvniak Jr.. Owner 1626 Plains Drive Eaton, CO 80615 (970)405-7716 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 Immunit 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 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 10 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 such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcontractor, 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. Proorietary 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 11 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 Emolovee of Weld Count 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. Entire Aereement 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. Aereement 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 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 12 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 sea. 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/Leeal Costs 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, 13 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: `�i� �I• K.«�K. Weld County Clerk to the Board By: Dep 14 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Mike Freeman, Chair MAY 1 12020 CONTRACTOR: KPJ First Services, LLC 1626 Plains Drive Eaton, CO 80615 (970) 405-7716 By: Keith Wawrzyniak (AUr 0 01 Keith P. Wawrzyniak, Jr., Owner Date: Apr 10, 2020 aoo2o -/03 74� 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.) This page intentionally left blank. KPJ FIRST SERVICES LLC. FAMILY AND Th1DIVIDUAJL RESOURCES, SUPPORT AND TRT.ATMEN"I' 928 13TH ST. #4C G12EELEY. CO 8O631 (970) 4O5-7716 KPW A W A@KPJFAMILYSER VICES. COM EXHIBIT B CONTRACTOR'S RESPONSE TO REQUEST FOR PROPOSAL Introduction Letter Weld County Administration, Keith Paul Wawrzyniak Jr. is the owner of KPJ FIRST Services LLC. and is interested in being a contract provider for the Weld County Department of Human Services. From 2007-2013, Keith Wawrzyniak, under the business name of Dynamic Family Design, LLC. contracted with Weld County to primary do Home Studies and Relinquishment Counseling, probably completing about 2-3 Home Studies a month. Since that time, I have worked in child welfare for Weld County. I have recently completed a Home Study refresher training and a Home Study Supervisor refresher training. I am planning on resigning from the Department, if I am accepted at a contract provider. It is my understanding that there is a significant need for Home Study Providers. Although I understand we are toward the end of the contract cycle, I am requesting and hoping that my request to be a Home Study Contractor, that it be expedited so I can help the Department with the Home Study process. I believe I have completed over 100 Home Studies in the past for Weld County and other Counties together. I am able to complete them in a professional manner, making sure they are thorough and complete prior to submitting them to the Department. I fully understand the new requirements of the providers when it comes to the Home Study process as stated in the RFP and in Exhibit "A", and am able to fulfill each requirement. I am able to work collaboratively with the Department and any other professionals who may be involved with the family of each Home Study. Brandon Williams is an LCSW and is attending the SAFE Home Study Certification Training at the end of February. He would be assisting me with Home Studies, when needed, under my supervision. KPJ FIRST Services plans to add additional scopes of services for the 2020-21 contract year, but in the mean time will be able to focus soley on Home Studies for Weld County. Sincerely, Keith Wawrzyniak, MSC. KPJ FIRST Services, LLC. Owner EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services KPJ FIRST Services LLC AGENCY OR PRIVATE PRACTICE Keith Wawrzvniak __ PRIMARY CONTACT— FULL NAME ( 970 1 405-7716 PHONE NUMBER kowawa14@AmaiLcorn PRIMARY CONTACT— E-MAIL ADDRESS 1626 Plains Dr. AGENCY MAILING ADDRESS TRAILS PROVIDER ID (If Known) Owner PRIMARY CONTACT - TITLE I J EXT, FAX NUMBER AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) Eaton 80615 CITY ZIP REFERRAL CONTACT Keith Paul Wawavniak Jr REFFERAL CONTACT— FULL NAME (9701405-7716 REFERRAL CONTACT —PHONE NUMBER EXT, BILLING CONTACT Keith PauIWawrniiiaklr. BILLING CONTACT —FULL NAME (970) 405-7716 BILLING CONTACT —PHONE NUMBER EXT. REFERRAL CONTACT - TITLE Imwawal4L�Amaii.com REFERRAL CONTACT— E-MAIL ADDRESS Owner BILLING CONTACT - TITLE knwawa14@zmall.com BILLING CONTACT— E-MAIL ADDRESS I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the specifications it has so indicated in this bid form. I further affirm intention to enter into an agreement with Weld County, on behalf of the Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept the bid, or part of a bid, that, in the opinion of the Board, is in the best interests of the Board and of the County of Weld, State of Colorado, The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are�cojpetitive in orrice and quality. _ Signature of Authorized Repressennttatiive: Date of Signature: I. f 'P Bid No.: B1900025 EXHIBIT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1- Provider and Program Area Information Bidder's Legal Name: KPJ FIRST Services, LLC Program Area: I_Home Studies Number of services offered on this Exhibit C (max 5): Program Areas are listed in column I of the table located in Item XI of the Request You may complete another Exhibit C if you have more than 5. for Proposal starting on page 13. Service #1 Name: SECTION 2 - Service Name(s) and Information Full -Home Study 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet 2.1b -This service will be provided by utilizing the required format of SAFE and tools provided by the Consortium for Children and Weld County DHS. -There will be interaction and observation of each member in any given household -The Home Studies will be completed within 60 days of receipt of all information needed to start the Home Study. -Al! required documentation will be delivered to WCDHS up completion of the Home Study.. -The Home Studies will be completed primarily by Keith Wawrzyniak. -Brandon Williams and Joanna Martinson will also be available to complete Home Studies under the supervision of Keith Wawrzyniak. of service per week (i.e. 4 hou -There will be a minimum of three visits to the home of a "couple-"- Home Study; each at a minimum of 1 % hours per visit. -There will be a: minimum of two visits to the home of a "single" Horne:Study at a minimum. of 1 % hours per visit. 2.1c Anticipated duration of service (i.e. 3-4 r To be completed within 60 days, barring any unforeseen issues or obstacles outside of the control of this der 2.1d Three (3). or pals of the service (DO use bullet -To provide a thorough and complete assessment of a family and their support systems, through observation and interviews using the tools required by the Department and SAFE. -To complete this evaluation in an objective and professional manner. -To be culturally aware, understanding and respectful. 2.1e Three (3), or more, specific outcomes of service: -Each family will receive a fair and objective assessment and will understand the reason for any recommendations of Weld County DHS will receive a thoroughly completed Home Study with all required documents. FIRST Services a recommendation of the level of appropriateness of placement and/or additional recommendations to mitigate any identified concerns. 2.1f Target population of the service, including age and I ICPCs, Kinship homes and foster family candidates 2.ig Languages service is available in (please list proficii A Spanish interpreter is available 2.1h Medicaid eligibility — list whether the service is elig and if interpreter services are for Medicaid in whole or in Service #2 Name: Updated -Home Study 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): REV. NOV 2019 I EXHIBIT C - PROPOSAL TEMPLATE -This service will be provided by utilizing the required format of SAFE and tools provided by the Consortium for Children and Weld County DHS. -There will be interaction and observation of each member in any given household -The Home Studies will be completed within 60 days of receipt of all information needed to start the Home Study. -All required documentation will be delivered to WCDHS up completion of the Home Study. -The Home Studies will be completed primarily by Keith Wawrzyniak. -Brandon Williams and Joanna Martinson will also be available to complete Home Studies under the supervision of Keith Wawrzyniak. 2.2b Anticipated frequency of service per week (i.e. 4 -There will be a minimum of three visits to the home of a "couple" Home Study, each at a minimum of 1 % hours per visit. -There will be a minimum of two visits to the home of a "single" Home Study at a minimum of I 34 hours per visit. 2.2c Anticipated duration of service (i.e. 3-4 months): To be completed within 60 days, barring any unforeseen issues or obstacles outside of the control of this provider 2.2d Three (3), or more, specific goals of the service (DO use bullet points): -To provide a thorough and complete assessment of a family and their support systems, through observation and interviews using the tools required by the Department and SAFE. -To complete this evaluation in an objective and professional manner. -To be culturally aware, understanding and respectful. 2.2e Three (3), or more, specific outcomes of service: -Each family will receive afair and objective assessment. -Each family will understand the reason for any recommendations �fthis.provid�rTTT -Weld County Di4S wi[I rece ve:a thoroughly completed SAFE Home Stud with all required documents. 2.2f Target population of the service: ICPCs, Kinship homes and. foster family candidates 2.2g Languages service is available in (please list proficiency and if interpreter services are available): A Spanish interpreter is available 2.zh Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NA Service #3 Name: Partial Home Study 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list ; DO use bullet -This service will be provided by utilizing the required format of SAFE and tools provided by the Consortium for Children and Weld County DHS. -There will be interaction and observation of each member in any given household -The Home Studies will be completed within 60 days of receipt of all information needed to start the Home Study. -All required documentation will be delivered to WCDHS up completion of the Home Study. -The Home Studies will be completed primarily by Keith Wawrzyniak. -Brandon Williams and Joanna Martinson will also be available to complete Home Studies under the supervision of Keith Wawrzyniak. 2.3b Anticipated frequency of service per week (i.e. 4 hours/week): REV. NOV 2019 2 EXHIBIT C - PROPOSAL TEMPLATE -There will be a. minimum of three visits to the home of a "couple" Home Study, each at a minimum of 1 % hours per visit. -There will be a minimum of two visits to the home of a "single" Home Study at a minimum of 1 hours per visit. 2.3c duration of service (i.e. 3-4 To be completed within 60 days, barring any unforeseen issues or obstacles outside of the control of this provider 2.3d Three (3), or more, specific goals of the service (DO use bullet points): 2.3e Three 2.3f -To provide a thorough and complete assessment of a family and their support systems, through observation and interviews using the tools required by the Department and SAFE. -To complete this evaluation in an objective and professional manner. -To be culturally aware, understanding and respectful. ), or more, specific outcomes of service: -Each family will receive a fair and objective assessment. -Each family will understand the reason for any recommendations of this provider. -Weld County DHS will receive a thoroughly completed SAFE Home Study with all required documents. 2.3g Language! A 5p nia shnia sh 2.3h Medicaid ulation of the service: hip homes and foster family candidates service is available in (please list profici nterpreter is available ligibility — list whether the service is elil Service #4 Name: tools used in of service (DO NOT list DO use bullet . 2.4a Modalities, curriculu 2.4b Antici of service week (i.e. 4 2.4c Anticipated duration of service (i.e. 3-4 and if interpreter services are availa for Medicaid in whole or in 2.4d Three (3), or more, specific goals of the service (DO use bullet 2.4e Three (3), or more, specific outcomes of service: 2.4f Tareet population of the service: 2.4g Languages service is available in (please list and if interpreter services are avai 2.4h Medicaid eligibility— list whether the service is eligible for Medicaid in whole or in Service #5 Name: 2.5a Modalities, curricu 2.5b 2.5c tools used in delivery of service (DO NOT list company history, DO use bullet of service per week (i.e. 4 hou duration of service (i.e. 3-4 REV. NOV 2019 3 EXHIBIT C - PROPOSAL TEMPLATE 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 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 3.1 3.2 3.3 Section 3 - Service Access and Transportation Will you conduct services in your office? My office is available when needed. 3.1a If yes, office location(s): 92813"Street. Greeley, CO 80631 —� Will you conduct services out of the office? YES -In -home visits 3.2a If yes, how many miles will you travel from your office? Weld County, I would consider out of County Will you transport clients to and from services? NO 3.3a If yes, what is your starting point address? 92813th street Greeley, CO 80631 3.3b If yes, how many miles will you travel from your starting point address? I Up to 120 miles SECTION 4- SERVICE RATES All rates need to include administrative work (i.e. report writing). Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly, daily, or monthly rates will be accepted for services, with the exception those listed above. Home study providers need to list their rates in 4.6. Monitored sobriety testing providers needs to list their rates in 4.7. 4.1 Service #1 Name: I T T7as ;; $ Amount Unit Type 4.1a In -Office rate: per 4.ib Out -of -office rate: per Catchment area in miles: 0 miles 4.1c FTM, TDM, Prof. Staffing: per 4.1d No show: 4.1e Mileage rate after catchment: per I per Mile 4.1f if the rate(s) listed above are a monthly l No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours 4.2 Service #2 Name: 4.2a In -Office Rate: 4.2b Out -of -Office Rate: 4.2c FTM, TDM, Prof. Staffing: 4.2d No show: 4.2e Mileage rate after catchment: TOTAL HOURS: complet per per per per $ Amount Unit Type 4.2f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: per per per per per Mile 2 the boxes below. month month month month Catchment area in miles: miles complete the boxes below. per month per month per month per month REV. NOV 2019 4 EXHIBIT C - PROPOSAL TEMPLATE 4.3 Service #3 Name: $ Amount Unit Type 4.3a In -Office Rate: 4.3b Out -of -Office Rate: 4.3c FTM, TDM, Prof. Staffing: 4.3d No show: 4.3e Mileage rate after catchment: 4.3f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: per per per per per Mile complet per per per per 4.4 Service #4 Name: 5 Amount Unit Tvoe 4.4a In -Office Rate: 4.4b Out -of -Office Rate: 4.4c FTM, TDM, Prof. Staffing: 4.4d No show: 4.4e Mileage rate after catchment: 4.41 If the rate(s) listed above are a monthly 1 No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: per per per per per Mile Catchment area in miles: II miles e the boxes below. month month month month Catchment area in miles: miles complete the boxes below. per month per month per month per month 4.5 Service #5 Name: - ,: $ Amount Unit Type 4.5a 4.5b 4.5c 4.5d 4.5e 4.6 Home In -Office Rate: - :TI per Out -of -Office Rate: FTM, TDM, Prof. Staffing: No show: Mileage rate after catchment: 4.5f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: Providers — List rates in the box below. per per - per per Mile Full Home Study Home Study (Updated/Addendum) *each additional adult(Full HS) *each additional adult(Updated HS) Partial Home Study Spanish Interpreter, if needed (Full -HS) Spanish Interpreter, if needed (Updated -HS) *mileage (outside of a 20 -mile radius from offi 4.7 Monitored Sobriety Providers — List your rates in the box below. Catchment area in miles: I __H miles iplete the boxes below. per month per month per month per month $1,200.00 $550.00 $200.00 $100.00 $60.00/hr $200.00 $100.00 $0.55/mile Provider special notes: REV. NOV 2019 5 EXHIBIT C - PROPOSAL TEMPLATE REV. NOV 2019 EXHIBIT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1 Provider and Program Area Information Bidder's Legal Name: KPJ FIRST Services, LLC Program Area: Facilitator Program Areas are listed in column I of the table located in Item XI of the Request for Proposal starting on page 13. Number of services offered on this Exhibit C (max 5): 2 You may complete another Exhibit C if you have more than 5. SECTION 2 - Service Name(s) and Information Service #1 Name: Facilitation of TDM's or high conflict FTM's 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Meeting rooms as arranged by the Department. Keith Wawrzyniak will apply facilitation skills as received in 24 hour of facilitation training skills through CWTS, along with his experience and connection with Weld County Department of Human Services for over 20 years.: 2.1b Anticipated frequency of service per week (i.e. 4 hours/week): Up to 10 meetings a week. Each meeting would be between 1-2 hour, but flexible to high profile cases. 2.1c Anticipated duration of service (i.e. 3-4 months): Ongoing 2.1d Three (3), or more, specific goals of the service (DO use bullet points): -To understand the purpose of the meeting and to help the group achieve the goals of the meeting. -To be the objective person of the meeting and provide structure, redirection, and support to the group as needed. -To keep the group on task within the allotted time. provided. To help all parties communicate their needs and understand the needs or concerns of others. -To help the group establish review original objectives, adjust objectives as needed and establish new objectives or goals to help them achieve the short and long term goals of the group. 2.1e Three (3), or more, specific outcomes of service: -Meeting will be completed with structure and in a timely manner. -There will be a clear understanding of what was accomplished, what are the next steps and a scheduled follow up meeting as needed. -To ensure that any concerns or unresolved issues were resolved and there is a plan in place to continue to work on mitigating any concerns. 2.1f Target population of the service, including age and gender: j Identified by the Department. Open to facilitate with any population or need 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility —list whether the service is eligible for Medicaid in whole or in part: NA REV. NOV 2019 EXHIBIT C - PROPOSAL TEMPLATE Service #2 Name: Facilitation of Family Team Meetings 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet -Meeting rooms as arranged.by the Department. -Keith Wawrzyniak will apply facilitation skills as received in 24 hour of facilitation training skills through CWTS, along with his experience and connection with Weld County Department of Human Services for over 20 years. 2.2b Anticipated frequency of service per week (i.e. 4 Up to 5 meetings a week. Each meeting would be between 1-2 hour, but flexible to high profile cases. 2.2c Anticipated duration of service (i.e. 3-4 As scheduled and needed by the Department 2.2d Three (3), or Is of the service (DO use bullet -To understand the purpose of the meeting and to help the group achieve the goals of the meeting. -To be the objective person of the meeting and provide structure, redirection, and support to the group as needed. -To keep the group on task within the allotted time provided. To help all parties communicate their needs and understand the needs or concerns of others. To help the group establish review original objectives, adjust objectives as needed and establish new objectives or goals to help them achieve the short and long-term goals of the group. 2.2e Three (3), or more, specific outcomes of service: -Meeting will be completed with structure and in a timely manner. -There will be a clear understanding of what was accomplished, what are the next steps and a scheduled follow up meeting as needed. -To ensure that any concerns or unresolved- issues were resolved and there is a plan in place to continue to work on mitigating any concerns. 2.2f Target population of the service: Identified by the Department. Open to facilitate with any population or need 2.2g Languages service is available in (please list proficiency and if interpreter services are avail; English _ 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NA Service #3 Name. 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.3b Anticipated frequency of service per week (i.e. 4 hours/week): 2.3c Anticipated duration of service (i.e. 3-4 2.3d Three (3), or more, specific goals of the service (DO use bullet 2.3e Three (3), or more, specific outcomes of service: 2.3f Target population of the service: 2.3g Languages service is available in (please list proficiency and if interpreter services are available): English -Interpreters to be provided by the Department. REV. NOV 2019 2 EXHIBIT C - PROPOSAL TEMPLATE 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NA Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of service per week (i.e. 4 hours/week): 2.4c Anticipated duration of service (i.e. 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: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #5 Name: 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of service per week (i.e. 4 hours/week): 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 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 conduct services in your office? [NO 3.la If yes, office location(s): 3.2 Will you conduct services out of the office? J Yes 3.2a If yes, how many miles will you travel from your office? Weld County 3.3 Will you transport clients to and from services? NO 3.3a If yes, what is your starting point address? 3.3b If yes, how many miles will you travel from your starting point address? SECTION 4- SERVICE RATES All rates need to include administrative work (i.e. report writing). Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly, daily, or monthly rates will be accepted for services, with the exception those listed above. Home study providers need to list their rates in 4.6. Monitored sobriety testing providers needs to list their rates in 4.7. REV. NOV 2019 3 EXHIBIT C - PROPOSAL TEMPLATE 4.1 Service #1 Name: I Team Decision Making Meeting/Considered Removal Team Decision Making Meeting $ Amount Unit Type 4.1a In -Office rate: 4.ib Out -of -office rate: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate after catchment: per NA per Hour Catchment area in miles: I! miles per Hour per visit per Mile 4.if If the rate(s) listed above are a monthly I No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: complete the boxes below. per month per month per month per month 4.2 Service #2 Name: I Family Team Meetings $ Amount Unit Type 4.2a In -Office Rate: NA per NA 4.2b Out -of -Office Rate: 95.00 per hour Catchment area in miles: �� miles 4.2c FTM, TDM, Prof. Staffing: 95.00 per hour 4.2d No show: 50.00 per visit 4.2e Mileage rate after catchment: per Mile 4.2f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: iplete the boxes below. per month per month per month per month 4.3 Service #3 Name: $ Amount Unit Type 4.3a In -Office Rate: 4.3b Out -of -Office Rate: 4.3c FTM, TDM, Prof. Staffing: 4.3d No show: 4.3e Mileage rate after catchment: 4.3f If the rate(s) listed above are a monthly I No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.4 Service #4 Name: per hour per Catchment area in miles: I miles per per per Mile complete the boxes below. per month per month per month per month $ Amount Unit Type 4.4a In -Office Rate: , per 4.4b Out -of -Office Rate: I per 4.4c FTM, TDM, Prof. Staffing: per 4.4d No show: per 4.4e Mileage rate after catchment: ? per 4.4f If the rate(s) listed above are a monthly 1 No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: Mile Catchment area in miles: II miles complete the boxes below. per month per month per month per month 4.5 Service #5 Name: $ Amount Unit Type REV. NOV 2019 4 EXHIBIT C - PROPOSAL TEMPLATE 4.5a In -Office Rate: 4.5b Out -of -Office Rate: 4.5c FTM, TDM, Prof. Staffing: 4.5d No show: 4.5e Mileage rate after catchment: per per per per Catchment area in miles: 0 miles per Mile 4.5f If the rate(s) listed above area monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.6 Home Study Providers - List your rates in the box below. • 4.7 Monitored Sobriety Providers- List your rates in the box below. Provider special notes: REV. NOV 2019 5 EXHIBIT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1 Provider and Program Area Information Bidder's Legal Name: KPJ FIRST Services, LLC Program Area: Home -Based Intervention Number of services offered on this Exhibit C (max 5): Program Areas are listed in column I of the table located in Item XI of the Request You may complete another Exhibit Cif you have more than 5. for Proposal starting an page 13. Service #1 Name: SECTION 2 — Service Name(s) and Information Home Based Intervention 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet -FIRST Services will utilize a Solution Focused Approach in the home working with families. -FIRST Services will respond in a timely manner to help the family deescalate any crisis or elevated situation in the home. -FIRST Services will be available by phone, 24/7 to help deescalate crisis situations that need,immediate response. -FIRST Services will help family create solutions and modify behaviors to deescalate crisis situations and maintain a safe environment in the home. -FIRST Services will help the family create short-term and long-term goals to maintain astable environment. -FIRST Services will help the parent develop stronger and more effective parenting skills. -FIRST Services will collaborate with other professionals to more effectively meet the needs of the family. -FIRST Services will maintain communication with the Department and other professionals involved via email and progress reports. 2.1b Anticipated frequency of service 4-8 hours -a week week (i.e. 4 hours 2.1c Anticipated duration of service (i.e. 3-4 2.1d Three (3). or 2.1e Three 2.1f Target p Families 2.1g Languag ;pals of the service (DO use bullet -lo .respond to families who are.in crisis in a timely manner and be,available for. them 24/7. -To intervene in difficult circumstances and help the family identify and mitigate immediate or existing concerns. -To continue to work with the family through behavior modification, strengthening parenting skills, establishing structure, clear expectations and boundaries and maintaining a safe environment. -To collaborate with professionals to ensure all the needs of the family are being met. -To help the family develop skills to resolve their conflicts and stressors. -For the family to reach out for support before a situation becomes a crisis. or more. specific outcomes of service: -FIRST Services will establish a healthy, trusting and supportive relationship with the family. -Each identified and communicated need of the family will be, addressed, met and/or additional services will be in place to continue to support the family. -The family maintains a safe home environment and utilizes learned skills and behaviors that maintain a healthier home and stronger emotional connections between them. -The family gains insight for the need for change. -The family will gain knowledge of and continue to utilize community resources for support. -The need for crisis response to the family will stop or decrease significantly. ulation of the service, including age and gender: ien with the Department. No perceived limitations, service is available in (please list proficiency and if interpreter services are availab 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NA Service #2 Name: REV. NOV 2019 1 EXHIBIT C - PROPOSAL TEMPLATE 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet r 2.2b Anticipated frequency of service per week (i.e. 4 hours/week): 2.2c Anticipated duration of service (i.e. 3-4 months): 2.2d Three (3), or more, specific goals of the service ([ 2.2e Three (3), or more, specific outcomes of service: 2.2f Target population of the service: 2.2g Languages service is available in (please list profi 2.2h Medicaid eligibility — list whether the service is e use bullet and if interpret for Medicaid in Service #3 Name: I 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list 2.3b Anticipated frequency of service per week (i.e. 4 hours/week): 2.3c Anticipated duration of service (i.e. 3-4 months) 2.3d Three (3), or more, specific goals of the service (. 2.3e Three (3), or more, specific outcomes of service: 2.3f Target population of the service: 2.3g Languages service is available in (please list prof 2.3h Medicaid eligibility — list whether the service is e use bullet services are ava iole or in nart: DO use bullet and if interpreter services are avai for Medicaid in whole or in part; Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list 2.4b Anticipated frequency of service per week (i.e. 4 hours/week): 2.4c Anticipated duration of service (i.e. 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: _ : DO use bullet points): 2.4f Target population of the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #5 Name: 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of service per week (i.e. 4 hours/week): REV. NOV 2019 2 EXHIBIT C - PROPOSAL TEMPLATE 2.5c Anticipated duration of service (Le. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 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 3.1 3.2 3.3 Section 3 — Service Access and Transportation Will you conduct services in your office? rNo 3.1a If yes, office location(s): j Will you conduct services out of the office? Yes 3.2a If yes, how many miles will you travel from your office? Weld County Will you transport clients to and from services? Yes 3.3a If yes, what is your starting point address? 92813`h St. Greeley, CO 80631 3.3b If yes, how many miles will you travel from your starting point address? Weld County SECTION 4- SERVICE RATES All rates need to include administrative work (i.ereport writing). Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly, daily, or monthly rates will be accepted for services, with the exception those listed above. Home study providers need to list their rates in 4.6. Monitored sobriety testing providers needs to list their rates in 4.7. 41 Service #1 Name: Home Based Intervention S Amount Unit Type 4.1a In -Office rate: NA per NA 4.1b Out -of -office rate: 125.00 per Hour Catchment area in miles: 20 miles tic FTM, TDM, Prof. Staffing: 65.00 per Hour 4.2d No show: 65.00 per Visit. 4.1e Mileage rate after catchment: .55 per Mile 4.1f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.2 Service #2 Name: _ S Amount Unit Tvoe 4.2a 4.2b 4.2c 4.2d 4.2e In -Office Rate: Out -of -Office Rate: FTM, TDM, Prof. Staffing: No show: Mileage rate after catchment: per per per per per Mile Catchment area in miles: miles 4.21 If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month REV. NOV 2019 3 EXHIBIT C - PROPOSAL TEMPLATE No. of travel hours per month TOTAL HOURS: L per month 4.3 Service #3 Name: $ Amount Unit Type 4.3a In -Office Rate: per 4.3b Out -of -Office Rate: per Catchment area in miles: miles 4.3c FTM, TDM, Prof. Staffing: per 4.3d No show: per 4.3e Mileage rate after catchment: per Mile 4.3f if the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: ____ per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.4 Service #4 Name: $ Amount Unit Type 4.4a In -Office Rate: per --� 4.4b Out -of -Office Rate: per Catchment area in miles: miles 4.4c FTM, TDM, Prof. Staffing: per 4.4d No show: per 4.4e Mileage rate after catchment: per Mile 4.4f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.5 Service #5 Name: $ Amount Unit Type 4.5a In -Office Rate: per 4.5b Out -of -Office Rate: s per Catchment area in miles: 0 miles 4.5c FTM, TDM, Prof, Staffing: per 4.5d No show: per 4.5e Mileage rate after catchment: per Mile 4.5f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.6 Home Study Providers — List your rates in the box below. 4.7 Monitored Sobriety Providers -List your rates in the box below. Provider special notes: REV. NOV 2019 EXHIBIT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1 Provider and Program Area Information Bidder's Legal Name: KPJ FIRST Services, LLC Program Area: Life Skills Program Areas are listed in column 1 of the table located in Item XI of the Request far Proposal starting on page 13. Service #1 Name: Mentor Number of services offered on this Exhibit C (max 5): 33 You may complete another Exhibit C if you have more than 5. SECTION 2 - Service Name(s) and Information 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): -FIRST Services will utilize a Solution Focused Approach in working with youth and families. - FIRST Services staff will meet with each youth weekly for the requested or approved amount of time by the Department. -FIRST Services staff will help teach the youth life skills, coping skills, emotional management, insight, and whatever else is determined to be support to the youth. -FIRST Services will help Child/Youth identify areas of needed change and solutions for change. -FIRST Services will help child/youth create a minimum of one goal per week to work on. Those goals will be reevaluated each week and adjusted at need. -FIRST Services will work will communicate with family, school, and other professionals involved with child/youth to help create more supportive environments to enable youth to be more successful. -FIRST Services staff will communicate the needs of the youth via phone or email to DHS worker. -FIRST Services staff wilt provide DHS worker documentation for each visit via email to include short-term and long-term goals, progress and any identified concerns. 2.1b Anticipated frequency of service per week (i.e. 4 hours/week): -FIRST Services staff are recommending 1-2 visits a week for 1-4 hours a visit, 4 to 8 hours a week. The mentor will comply with hours approved by the Department. -FIRST Services staff would start off being available for up to 10-15 hours a week for mentoring. -FIRST Services staff is only able to provide this service in North Weld County only. (Platteville and to the. North) r. 2.1c Anticipated duration of service (i.e. 3-4 mo I 2-4 months 2.1d Three (3), or more, specific goals of the service (DO use bullet points): -To identify the immediate problems and concerns of the child/youth. -To help the youth identify an immediate short-term solution or response to the issue(s) at hand and continue to work with the child/youth to develop some insight, coping skills, life skills and whatever other support that is needed by the youth and family. -To help youth effectively communicate needs and advocate for oneself in positive and productive manner. -To help the family be more supportive to the child/youth needs. -To Help youth remain in the home. 2.1e Three (3), or more, specific outcomes of service: -Child/you is able to remain in the home. -Child/youth utilizes new tools and skills to address problems that exist inside and outside of the home. -Child/youth begins to develop some self-awareness, confidence, insight, motivation and determination to make the necessary changes to be successful as a person and remain in his home. 211 Target population of the service, including age and Youth -11-17 years old, but Flexible to the request/ 2.1g Languages service is available in (please list proficii English and Spanish (Joe Garcia 2.1h Medicaid eligibility — list whether the service is elig Is of the Department. and if interpreter services are availab for Medicaid in whole or in REV. NOV 2019 1 EXHIBIT C - PROPOSAL TEMPLATE Service #2 Name: Supervised Visitation 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list 2.2b DO use bullet -FIRST Services will utilize a Solution Focused Approach in working with families. -FIRST Services will provide continuous observation during family visits. -FIRST Services will intervene with any concerning or unsafe behaviors and provide corrective measures for the family. -FIRST Services will evaluate roles, interactions, and family dynamics and provide feedback as needed. -FIRST Services will supervise the visit in office or out in the community. -FIRST Services will provide the Department with information of the progress and goals of the family. -FIRST Services will meet with parent(s) for 5-10 minutes after each visit and have them to identify any challenges during the visit and ask them for their insight as to what led to the challenging behavior/interaction and identify possible solutions for each challenging behavior/interaction. FIRST Services will share observed strengths and weaknesses with parent(s). - FIRST Services will set goal(s) with parent(s) to work on prior to the next visit and during the next visit. of service Per week (i.e. 4 As ordered by the Court or scheduled by the Department. 1-3 visits a week per family 2.2c Anticipated duration of service (i.e. 3-4 months): it will vary per family and the need of continued supervised visits will be a collaborative decision between the Department, FIRST Services and other professionals involved. 2.2d 2.2e 2.2f Three (3), or more, specific goals of the service (DO use bullet points): -To provide a safe and comfortable environment for the visit. -To provide constructive feedback for positive and negative behaviors of the children and parents. -To provide parents additional parenting skills to manage any challenging behaviors of the child(ren). -To ensure parents are able to meet the physical and emotional needs of the child(ren). -To help the family develop healthy physical and verbal interactions and communication. -To provide behavior coaching to the children as needed. Three (3), or more, specific outcomes of service: -The family has a safe and productive visit. -Parents develop skills to find solutions to the identified concerns and be able to utilize them at home -Parents are able to demonstrate insight to the root of the problem, need for change and benefit of the learned/changed behavior. a .. -Unwanted or unhealthy behaviors of the child(ren) decrease as the visits continue. -An observable increase in the emotional and ohvsical bond between parent(s) and child(ren). of the service: Families as identified by the Department 2.2g Languages service is available in (please list 2.2h Medicaid NO Service #3 Name: available. f — list whether the service is eli Therapeutic Supervision ( and if inter services are ble for Medicaid in whole or in part: 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list '; DO use bullet -FIRST Services will utilize a Solution Focused Approach in working with families. -FIRST Services will provide continuous observation during family visits. -FIRST Services will immediately intervene with any concerning or unsafe behaviors and provide corrective measures for the family. -FIRST Services will model appropriate behaviors and demonstrate appropriate parental reaction, verbal and physical, to challenging behaviors of a child. -FIRST Services will evaluate roles, interactions, and family dynamics and provide feedback as needed at the time of any observed concerns with child behavior or parenting. -FIRST Services will supervise the visit in office or out in the community. -FIRST Services will provide the Department with an evaluation of each visit and what the family is working on or needs to work on. -FIRST Services meet with parent for 10-15 minutes after visit and ask them to identify any challenges during the visit and ask them for their insight of what led to the challenging behavior/interaction and possible solutions for each challenging REV. NOV 2019 2 EXHIBIT C - PROPOSAL TEMPLATE behavior/interaction. FIRST Services will process with the parent any other observed concerning behaviors or interactions. -FIRST Services will help prioritize what needs to change. - FIRST Services will set goal(s) with parent to work on prior to the next visit and during the next visit. 2.3b Anticipated frequency of service per week (i.e. 4 hours/week): As ordered by the Court or scheduled by the Department. 1-3 visits a week per family 2.3c Anticipated duration of service (i.e. 3-4 months): It will vary per family and the need of continued supervised visits will be a. collaborative decision between the Department, FIRST Services and other professionals involved. _ lid Three (3), or more, specific goals of the service (DO use bullet points): -To provide a safe and comfortable environment for the visit. -To ensure parents are not under the influence of any substance. To help the parent prioritize are -To provide continual and constructive feedback for positive and negative behaviors of the children and parents. -To provide parents additional parenting skills to manage any challenging behaviors of the child(ren). -To help the parents identify ways to meet the physical and emotional needs of the child(ren) in a healthy manner. To educate the parents of the importance of an emotional bond and to teach them new skills to strengthen that bond and relationship with their child(ren). -To help the parents develop insight and skills to identify the source of conflict, obstacles and triggers and to create a solution or change in behavior to resolve the issues during the visits and at home. 2.3e Three (3), or more, specific outcomes of service: The family has a safe and productive visit. -Parents learn new parenting skills they practice during these visits and utilize at home. -Parents are able to communicate insight to the source of the problem or behavior, find solutions and identify the benefit of the new parenting practices they learn during the visits. -Unwanted behaviors of the child(ren) decrease as the visits continue. -An observable increase in the emotional and physical bond between parent(s) and child(ren). -Parents utilize new learned parenting skill with the children during following visits. -Children demonstrate appropriate behaviors and demonstrate better responses to the parent(s). 2.3f Target population of the service; Families as identified by the Department,. 2.3g Languages service is available in (please list proficiency and if interpreter services are available): English. Spanish interpreter available. 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NO Service #4 Name: 2.4a Modalities, curriculum, tools used in of service (DO NOT list 2.4b Anticipated frequency of service per week (i.e. 4 hours/week) 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3). or more, specific goals of the service (DO use bullet 2.4e Three 2.4f 2.4g La or more, specific outcomes of service: of the service: service is available in (please list 2.4h Medicaid ell; Service #5 Name: r - list whether the service is eli DO use bullet and if interpreter services are availab for Medicaid in whole or in 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): REV. NOV 2019 3 EXHIBIT C - PROPOSAL TEMPLATE 2.5b Anticipated frequency of service per week (i.e. 4 hours/week): 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.Sg 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 3.1 3.2 3.3 Section 3 — Service Access and Transportation Will you conduct services in your office? Yes 3.1a if yes, office location(s): 92813th st. Greeley, CO 80631 Will you conduct services out of the office? Yes 3.26 If yes, how many miles will you travel from your office? We!d County Will you transport clients to and from services? f Yes 33a If yes, what is your starting point address? _..92813th St. Greeley,.CO 80631 3.3b If yes, how many miles will you travel from your starting point address? 20 SECTION 4- SERVICE RATES All rates need to include administrative work (i.e. report writing). Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly, daily, or monthly rates will be accepted for services, with the exception those listed above. Home study providers need to list their rates in 4.6. Monitored sobriety testing providers needs to list their rates in 4.7. 4.1 Service #1 Name: Mentor $ Amount Unit Type 4.1a In -Office rate: 65.00 per hour 4.1b Out -of -office rate: 65.00 per hour Catchment area in miles: 20 miles 4.1c FTM, TDM, Prof. Staffing: ! 65.00 per 4.1d No show: 1 45.00 per 4.1e Mileage rate after catchment: NA per 4.11 If the rate(s) listed above are a monthly pac No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.2 Service #2 Name: 4.2a 42b 4.2c 4.2d 4.2e hour visit _i Mile complete the boxes below. per month per month per month per month Supervised Visits $ Amount Unit Type In -Office Rate: 75.00 per hour Out -of -Office Rate: FTM, TDM, Prof. Staffing: No show: Mileage rate after catchment: 105.00 65.00 65.00 .55 per hour Catchment area in miles: 20 miles per hour per visit per Mile 4.2f if the rate(s) listed above are a monthly package, complete the boxes below. REV. NOV 2019 4 EXHIBIT C - PROPOSAL TEMPLATE No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month J TOTAL HOURS: per month 4.3 Service #3 Name: Therapeutic Supervised Visits $ Amount Unit Type 4.3a 4.3b In -Office Rate: 85.00 per Out -of -Office Rate: 125.00 per hour hour Catchment area in miles: 20 I miles 4.3c FTM, TDM, Prof. Staffing: 65.00 per hour 4.3d No show: 65.00 ; per { visit 4.3e Mileage rate after catchment: .55 ! per Mile 4.3f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: No. of travel hours per per month month TOTAL HOURS: per month 4.4 Service #4 Name: I __ $ Amount Unit Type 4.4a 4.4b In -Office Rate: ; per Out -of -Office Rate: ! per _ _ _ Catchment area in miles: ] miles 4.4c FTM, TDM, Prof. Staffing: ; per F 4.4d No show: ; per 4.4e Mileage rate after catchment: per Mile 4.4f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.5 Service #5 Name: $ Amount Unit Type 4.5a In -Office Rate: per 4.5b Out -of -Office Rate: per Catchment area in miles: miles 4.5c FTM, TDM, Prof. Staffing: per F 4.5d No show: per 4.5e Mileage rate after catchment: per Mile 4.5f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.6 Home Study Providers — List your rates in the box below. 4.7 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: additional REV. NOV 2019 EXHIBIT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1 Provider and Program Area Information Bidder's Legal Name KPJ FIRST Services, LLC Program Area: Relinquishment Counseling Program Areas are listed in column 1 of the table located in Item XI of the Request for Proposal starting on page 13. Number of services offered on this Exhibit C (max 5): 11 You may complete another Exhibit Cif you have more than 5. SECTION 2 - Service Name(s) and Information Service #1 Name: Relinquishment Counseling 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): - Family Services will only use documents approved by the Department. -Family Services will meet with each client for approximately an hour or whatever time is needed to ensure the client understands the finality of his/her decision. -Family Services will attempt to ensure that any client is not under the influence of any kind of -substance during the session. The session will be rescheduled if it is perceived that a client is under the influence of anything. -The affidavit for Relinquishment Counseling and Relinquishment Interrogatory will by notarized (if required). 2.1b Anticipated frequency of service per week (i.e. 4 hours/week): This will consist of one office visit for approximately 1-2 hours 2.1c Anticipated duration of service (i.e. 3-4 months): 1 visit and 1-2 hours 2.1d Three (3), or more, specific goals of the service (DO use bullet points): -To thoroughly explain the meaning of "termination of parental rights" to the parent and to ensure he/she fully understand the finality of his/her decision. -To ensure the parent understands they no. longer have any decision -making rights for their child. -To ensure the parent understands he/she A0 longer has a right to contact with their child(ren):" 2.1e Three (3), or more, specific outcomes of service: -To thoroughly explain the meaning of "termination of parental rights" to the parent and to ensure he/she fully understand the finality of his/her decision. -To ensure the parent understands they no longer have any decision -making rights for their child. -To ensure the parent understands he/she no longer has a right to contact with their child(ren). 2.1f Target population of the service, including age and gender: Parents 2.1g Languages service is available in (please list proficiency and if interpreter services are available): _ Spanish Interpreter is available _ 2.1h Medicaid eligibility —list whether the service is eligible for Medicaid in whole or in part: --- NA Service #2 Name: r 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.2b Anticipated frequency of service per week (i.e. 4 hours/week): 2.2c Anticipated duration of service (i.e. 3-4 months): 2.2d Three (3), or more, specific goals of the service (DO use bullet points): REV. NOV 2019 1 EXHIBIT C - PROPOSAL TEMPLATE 2.2e Three (3), or more, specific outcomes of service: _ 2.2f Target population of the service: 2.2g Languages service is available in (please list proficiency and if interpreter services are available): 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #3 Name: 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history 2.3b Anticipated frequency of service per week (i.e. 4 hours/week): 2.3c Anticipated duration of service (i.e. 3-4 months): 2.3d Three (3), or more, specific goals of the service (DO use bullet points): 2.3e Three (3), or more, specific outcomes of service: 2.3f Target population of the service: 2.3g Languages service is available in (please list proficiency and if interpreter services are 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in pa Service #4 Name: 2.4a Modalities, cur 2.4b Anticipated fre 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or m 2.4e Three (3), or m 2.4f Target population of the service: 2.4g Languages service is available in (please list prc 2.4h Medicaid eligibility — list whether the service is DO use bullet points): Service #5 Name: , tools used in of service Der goals of the service ([ outcomes of service: of service 4 hours) NOT list use bullet DO use bullet and if interpreter services are ava for Medicaid in whole or in Dart: 2.sa Modalities, curriculum, tools used in delivery of service (DO NOT list c 2.5b Anticipated frequency of service per week (i.e. 4 hours/week): 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: DO use bullet REV. NOV 2019 2 EXHIBIT C - PROPOSAL TEMPLATE 2.5f 2.5g of the service: es service is available in (please list and if services are 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 conduct services in your office? YES 3.la if yes, office location(s): 92813`h Street. Greeley, CO 80631 3.2 Will you conduct services out of the office? Yes 3.2a If yes, how many miles will you travel from your office? F Weld County. 3.3 Will you transport clients to and from services? i NO 3.3a If yes, what is your starting point address? NA 3.3b If yes, how many miles will you travel from your starting point address? NIA' SECTION 4- SERVICE RATES All rates need to include administrative work (i.e. report writing). Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly, daily, or monthly rates will be accepted for services, with the exception those listed above. Home study providers need to list their rates in 4.6. Monitored sobriety testing providers needs to list their rates in 4.7. 4.1 Service #1 Name: i Relinquishment Counseling $ Amount Unit Type 4.1a In -Office rate: 95.00 ' oer hour -150.00 65.00 -65.00 .55 4.1b Out -of -office rate: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate after catchment: per hour per hour per visit per Mile 4.lf If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: Catchment area in miles: 20- miles iplete the boxes below. per month per month per month per month 4.2 Service #2 Name: $ Amount Unit Type 4.2a In -Office Rate: 4.2b Out -of -Office Rate: 4.2c FTM, TDM, Prof. Staffing: 4.2d No show: 4.2e Mileage rate after catchment: 4.2f If the rate(s) listed above are a monthly 1 No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.3 Service #3 Name: 4.3a 4.3b per per per per per Mile Catchment area in miles: miles :kage, complete the boxes below. per month per month per month per month $ Amount Unit Type In -Office Rate: per Out -of -Office Rate: per Catchment area in miles: miles REV. NOV 2019 3 EXHIBIT C o PROPOSAL TEMPLATE 4.3c FTM, TDM, Prof. Staffing: per 4.3d No show: per v`_y 4.3e Mileage rate after catchment: per Mile 4.3f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.4 Service #4 Name: $ Amount Unit Type 4.4a In -Office Rate: per 4.4b Out -of -Office Rate: per . Catchment area in miles: miles 4.4c FTM, TDM, Prof. Staffing: per 4.4d No show: per 4.4e Mileage rate after catchment: per Mile 4.4f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours ! per month TOTAL HOURS: per month 4.5 Service #5 Name: $ Amount Unit Type 4.5a In -Office Rate: per 4.5b Out -of -Office Rate: per Catchment area in miles: baL,__ miles 4.5c FTM, TDM, Prof. Staffing: per 4.5d No show: per 4.5e Mileage rate after catchment: per Mile 4.5f If the rate(s) listed above are a,monthly package, complete the boxes below. • No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.6 Home Study Providers — List your rates in the box below. 4.7 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: REV. NOV 2019 EXHIBIT D STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine s PROPOSED SERVICE OR SERVICE TYPE Home Studies BIDDER LEGAL ENTITY NAME: KPJ FIRST Services, LLC. APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION 1 `_ , n ;";_: _4yx� ''' " I' Legal Last Legal First Name Work# Education Work Email Level D� gree Focus Licensure/ Credentials DORA (If applicable) .r i Yom^` �N�r i i1 �y dJf iName °No. 1 Wawrzyniak Keith (970)405-7716 k wawa@k 'famil services.co Counseling MSC NL13374 2 Williams Brandon (970)301-8214 Bkwsrni7O@iclouc LCSW Social Work LCSW1581 NA Wawrzyniak Keith (970)4 3 Martinson Joanna (970)302-2115 tisds@aol.com Register Nurse Nursing -Psych RN NA Wawrzyniak Keith (970)4 4 NA 5 6 7 8 9 10 11 12 13 .____________ 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 B1800058 STAFF DATA SHEET EXHIBIT D (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine si PROPOSED SERVICE OR SERVICE TYPE: Horne -Based Intervention BIDDER LEGAL ENTITY NAME: KPJ FIRST Services, LLC. . APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION Y i a a ;`°; . No, Legal Last Name Leal First Name `. Work# Work Email Education Level Degree Focus Lic ensure/. Credentials DORA# (If applicable)ami' .,.c&Y a' ,� %. >i1..5YR_m'Lli3l k. `:si "r'gVlO 1 Wawrzyniak Keith (970)405-7716 kpwawa@kpifamilyservices.coi Counseling MSC NL13374 2 Williams Brandon (970)301-8214 Bkwsmi70@iclou LCSW Social Work LCSW1581 NA Wawrzyniak Keith (9; 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 B1800058 STAFF DATA SHEET EXHIBIT D (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine s PROPOSED SERVICE OR SERVICE TYPE: Life Skills -Mentor BIDDER LEGAL ENTITY NAME: KPJ FIRST Services, LLC. APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION a,a•. rR F..)5T _v�*r r t �.., l ♦insL._• No. Legal Last Name Legal First Name • Work# .. " Work Email �y/r /�p� Education Level Degree Focus Licensure/ Lwcensure/ Credentials DORA #' (If . applicable) 5p t, f ��st� ^, v' j �S`' vnfl, k6'4 `+<4[ I �avy.'j��c }w J'i rAt.�S k\A!s\Jz ��-�.,�m�µ�Y�°�,Ir.�,qqua.4{�;s��1�*,�,A•,5,�$•.-I�'��., yi� 1f... Idu A t $ 41^c 3' ♦3y4£z�3 t�" M,�d �in A ^. iS �Pv�1 Yi'tA L1Yr.I1A . A NdO\7\ h♦y''` y yry�tyrtSei� .rl� ,J 'tIIV ,� fr kY^[s . y1Y `?��,� �] lii✓tiv , G {A•lt lyd+v'6y.¢. , a'R 1 Wawrzyniak Keith (970)405-7716 kpwawa @ kpifamilys Counseling MSC NL13374 ervices.com 2 Williams Brandon (970)301-8214 Bkwsmi70@icloud.co LCSW Social Work LCSW1581 NA Wawrzyniak Keith (970)41 3 Garcia Joe (970)301-6012 im arcial2 hotmaiL HS Psychology Behavior Health Specialist NA Wawrzyniak Keith (970)4 4 Nemeth Frank (970)396-3325 ronokco2016@gmail.comBS Psychology Behavior Health Specialist NA Wawrzyniak Keith (970)4' 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 B1800058 Account Number: CO KPJF 1620 Date: 1/22/20 Initials: CA CERTIFICATE OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named Insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Named Insured: KPJ FIRST SERVICES LLC 1626 PLAINS DRIVE EATON CO 80615 Type of Work Covered: MENTAL HEALTH COUNSELOR Location of Operations: N/A (It different than address listed above) Claim History: RetrnartivP ciai is 11/1R/2019 Additional Named Insureds: KEITH P WAWRZYNIAK JR Coverages Policy Number Effective Date Expiration Date Limits of Liability PROFESSIONAL/ LIABILITY 5005-4078 11/18/19 11/18/20 1,000,000 3,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: Defense Reimbursement Proceedings Limit is $5,000. 1 ADDL.INS.BELOW: BOARD OF COUNTY COMM. OF WELD COUNTY & ITS OFFICERS /EMPLOYEES This Certificate Issued to: Name: KPJ FIRST SERVICES LLC 1626 PLAINS DRIVE Address: EATON CO 80615 ized Representative APA 00138 00 (06/2014) EXHIBIT C SCOPE OF SERVICES 1. Contractor will conduct Home Studies, as referred by the Department. 2. Capacity for Services: Varied; approximately one and a half hours (1.5) hours per week. 3. Contractor will conduct the following types of Home Studies: i. Kinship Care ii. Foster Care iii. Kinship Foster Care iv. Parent Care v. Foster -Adoption vi. Adoption vii. Interstate Compact on the Placement of Children (ICPC) 4. Contractor is certified in Structured Analysis Family Evaluation (SAFE) and is on the State's approved home study vendor list. Contractor also is certified as a SAFE Supervisor. 5. Contractor will utilize the most current Structured Analysis Family Evaluation (SAFE) forms and templates. Contractor will ensure all home studies completed for the Department include, at a minimum, all the following: a. SAFE Home Study template. b. Compatibility Inventory. c. References and documented direct follow-up with references (phone call or meeting). d. Psychosocial Inventory for all applicants. e. Questionnaire I and II for all applicants. f. Indian Child Welfare Act (ICWA)/Indian heritage discovery and documentation. g. All additional collateral information collected from the applicants. h. Urinalysis (UA) result from a certified testing facility, if requested by the Department. A UA will be required for any individual 18 or older residing in the home, when requested by the Department, if substance abuse concerns are noted. The cost of the UA will be responsibility of the applicant. 6. Contractor will meet regularly with Department staff during the home study process. At a minimum, Contractor will meet with Department staff as follows: a. Following completion of individual applicant meetings. b. Three (3) weeks after the completion of individual applicant meetings. c. Prior to the final review with the applicant(s). 7. Contractor understands that reimbursement for partial home studies will only occur after the following: a. At least one (1) face-to-face meeting and two (2) phone contacts, and b. A letter has been submitted to the Department documenting why the study cannot move forward. 8. Location of Services: • In practitioner's office located at 928 13th Street, Greeley, CO 80631. • In referred applicant's home. • Within Weld County. Consideration will be given to areas outside of Weld County. 9. Language: English. A Spanish speaking interpreter is available upon request. 10. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 11. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). 12. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation 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" on the part of the client per month. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). 13. 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 Supervisor (hainleid@weldgov.com) immediately via email, to discuss service continuation. 14. 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. 15. 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. 16. 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. 17. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. 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. 18. Contractor will notify the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210) 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. EXHIBIT C SCOPE OF SERVICES a. Contractor will provide Facilitation, Home -Based Intervention, Life Skills, and Relinquishment Counseling Services, as referred by the Department. Facilitation of TDM's, High Conflict FTM's and Family Team Meetings: b. Modalities, Curriculum, or Tools: Contractor will utilize facilitation skills in the provision of services. c. Anticipated Frequency of Services: a. TDM's or High Conflict FTM's — One (1) to two (2) hours per session, up to ten (10) meetings per week. b. Family Team Meetings - One (1) to two (2) hours per session, up to five (5) meetings per week. d. Anticipated Duration of Services: a. As determined by the Department. e. Goals of Service: a. Provide structure and redirection to the client. b. Increase communication skills. c. Assist client with obtaining short and long-term goals. f. Outcome of Service: Contractor will tailor outcomes to each individual and match the outcome to the individual and Department needs. Common outcomes include: a. Objectives are accomplished. b. Develop a plan to address any unresolved concerns. g. Target Population: a. Contractor does not discriminate based on race, gender, religion, national origin, physical or mental disability, age, sexual orientation or gender identity. h. Service Access: a. In referred applicant's home. b. Within Weld County. i. Available Language(s): a. English. b. A Spanish speaking interpreter is available upon request. Home -Based Intervention: j. Modalities, Curriculum, or Tools: Contractor will utilize a Solution Focused Approach in the provision of services. Contractor will help families to create solutions and modify behaviors to de-escalate crisis situations and maintain a safe environment in the home. Contractor will collaborate with other professionals to more effectively meet the needs of the family. Contractor will parents in developing stronger more effective parenting skills. k. Anticipated Frequency of Services: c. Four (4) to eight (8) hours per week. d. Contractor will be available 24 hours per day, seven (7) days per week. 1. Anticipated Duration of Services: a. One (1) to three (3) months. m. Goals of Service: a. To intervene in difficult circumstances and help the family to identify and mitigate immediate or existing concerns. b. To respond to families in a crisis. c. Assist families in accessing community resources and support. n. Outcome of Service: a. Establish a healthy, trusting and supportive relationship with the family. b. The family will gain knowledge or and continue to utilize available community resources. c. Decrease the need for crisis response. d. Family gains insight for the need for change. o. Target Population: a. Contractor does not discriminate based on race, gender, religion, national origin, physical or mental disability, age, sexual orientation or gender identity. p. Service Access: a. In referred applicant's home. b. Within Weld County. c. Contractor will provide transportation services within Weld County. q. Available Language(s): a. English. b. A Spanish speaking interpreter is available upon request. Mentoring: r. Modalities, Curriculum, or Tools: Contractor will utilize a Solution Focused Approach in the provision of services. s. Anticipated Frequency of Services: e. Four (4) to eight (8) hours per week. t. Anticipated Duration of Services: a. Two (2) to four (4) months. u. Goals of Service: a. To help youth effectively communicate needs and advocate for oneself in positive and productive manner. b. To help youth identify an immediate short-term solution or response to the issue(s) at hand. c. To help youth effectively communicate needs and advocate for oneself in positive and productive manner. v. Outcome of Service: a. Youth develop new tools and skills to address issues that exist inside and outside of the home. b. Youth develop self-awareness, confidence, insight, determination and motivation. c. Parents develop stronger more effective parenting skills. d. Child can remain in the home. w. Target Population: a. Youth ages 11 to 17 years. x. Service Access: a. In practitioner's office located at 928 13th Street, Greeley, CO 80631. b. In referred applicant's home. c. Within Weld County. d. Contractor will provide transportation services within 20 miles of practitioner's office located at 928 13th Street, Greeley, CO 80631. y. Available Language(s): a. English. b. A Spanish speaking interpreter is available upon request. Supervised Visitation: z. Modalities, Curriculum, or Tools: Contractor will provide supervised visitation services in -office or in the client's home. Contractor utilizes a Solution Focused Approach in the provision of services. aa. Anticipated Frequency of Services: f. As ordered by the court g. As directed by the Department. bb. Anticipated Duration of Services: a. As directed by the Department. cc. Goals of Service: a. Provide constructive feedback for positive and negative behaviors exhibited by the children and parents. b. Develop healthy physical and verbal communication skills. c. Ensure parents meet the physical and emotional needs of the children. d. Evaluate roles, interactions, and family dynamics and provide feedback as needed. e. Provide training in life skills, emotional management, and coping skills. dd. Outcome of Service: a. Parents demonstrate insight as to the root of the problem, and the need for change. b. Unwanted or unhealthy behaviors of the child decrease as visits continue. c. An observable increase in the emotional and physical bond between the child(ren) and the parent(s). ee. Target Population: a. As designated by the Department. ff. Service Access: a. In practitioner's office located at 928 13th Street, Greeley, CO 80631. b. In referred applicant's home. c. Within Weld County. d. Contractor will provide transportation services within twenty (20) miles of practitioner's office located at 928 13th Street, Greeley, CO 80631. gg. Available Language(s): a. English. b. A Spanish speaking interpreter is available upon request. Therapeutic Supervision: hh. Modalities, Curriculum, or Tools: Contractor will utilize a Solution Focused Approach in the provision of services. ii. Anticipated Frequency of Services: a. As ordered by the court. b. As directed by the Department. jj. Anticipated Duration of Services: a. As designated by the Department. kk. Goals of Service: a. Provide constructive feedback for positive and negative behaviors. b. Provide parents with the skills to manage challenging behaviors. c. Identify ways to meet the physical and emotional needs of the child(ren) in a healthy manner. d. Educate parents on the importance of establishing and strengthening the emotional bond with their child(ren). 11. Outcome of Service: a. Parents develop new parenting skills a. Increased emotional and physical bond between the child(ren) and the parent(s). b. Children demonstrate appropriate behaviors and better responses to parents. c. Parents acquire and demonstrate new parenting skills. mm. Service Access: a. In practitioner's office located at 928 13' Street, Greeley, CO 80631. b. In referred applicant's home. c. Within Weld County. d. Contractor will provide transportation services within twenty (20) miles of practitioner's office located at 928 13th Street, Greeley, CO 80631. nn. Available Language(s): a. English. b. A Spanish speaking interpreter is available upon request. Relinquishment Counseling: oo. Modalities, Curriculum, or Tools: Contractor will provide Relinquishment Counseling services as referred by the Department. pp. Anticipated Frequency of Services: c. One (1) office visit. qq. Anticipated Duration of Services: a. One (1) to (2) hours. rr. Goals of Service: a. To educate and ensure that parent(s) understand the elements involved in termination of parental rights, including: i. Loss of decision- making rights for child(ren). ii. Loss of contact with child(ren). ss. Outcome of Service: a. To educate and ensure that parent(s) understand the elements involved in termination of parental rights, including: i. Loss of decision- making rights for child(ren). ii. Loss of contact with child(ren). tt. Target Population: a. As identified by the Department. uu. Service Access: a. In practitioner's office located at 928 131 Street, Greeley, CO 80631. b. In referred applicant's home. c. Within Weld County. d. Contractor will not provide transportation services for clients. vv. Available Language(s): a. English. b. A Spanish speaking interpreter is available upon request. ww. Contractor will respond to the Quality Assurance Team Supervisor (hainlejd(weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. xx. 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 Supervisor (hainleid(i�weldgov.com, 970-400-6210). yy. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. 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 Supervisor (hainleid(a�weld off, 970-400-6210). zz. 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 Supervisor (hainleid(a�weld og v.com) immediately via email, to discuss service continuation. aaa. 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. bbb.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. ccc. 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. ddd.Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. 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. eee. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as the meeting is at least one hour in length, 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. 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. fff. Contractor will notify the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210) 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. EXHIBIT D RATE SCHEDULE 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, 2021. 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 $1,200.00/Each (Full Home Study) $200.00/Each additional adult (Full Home Study) $60.00/Hour (Partial Home Study) $550.00/Each (Home Study Update) $100.00/Each additional adult (Home Study Update) $ .55/Mile (Mileage) — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. $200.00/Each (Spanish Interpreter Fee — Full Home Study) $100.00/Each (Spanish Interpreter Fee — Home Study Update) 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. 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, 2021. 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. Fees for Services Facilitation of TDM's or High Conflict FTM's $115.00/Hour (Out -of -Office) $115.00/Hour (FTM, TDM, Prof. Staffing) $50.00/Visit (No show) Family Team Meetings $95.00/Hour (Out -of -Office) $95.00/Hour (FTM, TDM, Prof. Staffing) $50.00/Visit (No show) Home Base Intervention $125.00/Hour (Out -of -Office) $65.00/Hour (FTM, TDM, Prof. Staffing) $65.00/Visit (No show) $ .55/Mile (Mileage) — For distance exceeding twenty (20) miles from practitioner's office located at 928 13`h Street, Greeley, CO 80631. Mentor $65.00/Hour (In -Office) $65.00/Hour (Out -of -Office) $65.00/Hour (FTM, TDM, Prof. Staffing) $45.00/Visit (No show) $35.00/Hour (Spanish Interpreter) Supervised Visitation $75.00/Hour (In -Office) $105.00/Hour (Out -of -Office) $65.00/Hour (FTM, TDM, Prof. Staffing) $65.00/Visit (No show) $35.00/Hour (Spanish Interpreter) $ .55/Mile (Mileage) — For distance exceeding twenty (20) miles from practitioner's office located at 928 13`h Street, Greeley, CO 80631. Therapeutic Supervised Visits $85.00/Hour (In -Office) $125.00/Hour (Out -of -Office) $65.00/Hour (FTM, TDM, Prof. Staffing) $65.00/Visit (No show) $35.00/Hour (Spanish Interpreter) $ .55/Mile (Mileage) — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. Relinquishment Counseling $95.00/Hour (In -Office) $150.00/Hour (Out -of -Office) $65.00/Hour (FTM, TDM, Prof. Staffing) $65.00/Visit (No show) $ .55/Mile (Mileage) — For distance exceeding twenty (20) miles from practitioner's office located at 928 13th Street, Greeley, CO 80631. 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. Account Number: CO KPJF 1620 Date: 4/27/20 Initials: LISAB CERTIFICATE OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named Insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Named Insured: KPJ FIRST SERVICES LLC 1626 PLAINS DRIVE EATON CO 80615 Type of Work Covered: MENTAL HEALTH COUNSELOR Location of Operations: N/A (If different than address listed above) Claim History: Ratrnar'iva data i cz l l /l R/2fll 9 Additional Named Insureds: KEITH P WAWRZYNIAK JR Coverages Policy Number Effective Date Expiration Date Limits of Liability PROFESSIONAL/ BUSINESS LIABILITY 5005-4078 11/18/19 11/18/20 1,000,000 3,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: THE FOLLOWING ENTIYT IS LISTED AD AN ADDITIONAL INSURED ON THE ABOVE POLICY: *THIS POLICY INCLUDES GENERAL BOARD OF COUNTY COMM. OF BUSINESS LIABILITY WELD COUNTY & ITS OFFICERS /EMPLOYEES This Certificate Issued to: Name: KPJ FIRST SERVICES LLC 1626 PLAINS DRIVE Address: EATON CO 80615 Aut$orized Representative APA 00138 00 (06/2014) New Contract Request Entity Information Entity Name* Entity ID* ❑ New Entity? KPJ FIRST SERVICES. LLC @00041915 Contract Name * Contract ID Parent Contract ID KPJ FIRST SERVICES, LLC (NEW CW PROTECTION 3535 AGREEMENT FOR SERVICES) Contract Lead* Requires Board Approval Contract Status CULLINTA YES CTB REVIEW Contract Lead Email Department Project I cuUinta@co.weld.co.us Contract Description CONSENT. BID NO, 2000037. NEW AGREEMENT FOR SERVICES. TERM JUNE 1, 2020 THROUGH MAY 31, 2021. FUNDING CORE/OTHER Contract Description 2 Contract Type'* Department Requested BOCC Agenda Due Date AGREEMENT HUMAN SERVICES Date* 04,11&/2020 04/22/2020 Amount* Department Email $0.00 CM- Will a work session with BOCC be required?* HumanServices@weldgov.com NO Renewable YES Department Head Email Does Contract require Purchasing Dept. to be included? CM-HumanServices- Automatic Renewal DeptHead@weldgov.com County Attorney Grant GENERAL COUNTY ATTORNEY EMAIL IGA County Attorney Email Chr1- COUNTYATTOR.N EY o@WELD GOV. COM 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 Contract Dates Effective Date Review Date * Renewal Date* 04/01)2021 06/01/2021 Termination Notice Period Committed Delivery Date Expiration Date Contact Information Contact Info Contact Name Purchasing Purchasing Approver Approval Process Department Head JAMIE ULRICH DH Approved Date 05/0512020 Final Approval BOCC Approved ROCC Signed Date BOCC Agenda Date 05/11/2020 Originator SNYDERKL Submit Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Approved Date Finance Approver BARB CONNOLLY Finance Approved Date 0510612020 Tyler Ref # AG 051120 Legal Counsel GABE KALOUSEK Legal Counsel Approved Date 05/06//2020 Hello